New AMSA application1 by Nc7M7xzF

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For Office Use ONLY: Fees Received: ____
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Updated as of 10/30/11

AMSA Local Membership Application
AMSA Baylor Premedical membership shall be available to any student attending Baylor
University who demonstrates a serious interest in the profession of medicine. All potential
members shall meet and abide by the requirements of the local chapter and pay the required
premedical sustaining dues of the Association in order to be considered an "active" member. An
affiliate member of AMSA is not a part of National AMSA. The member will receive all benefits of
being a part of the AMSA BU chapter, but cannot partake in National AMSA activities without a
separate membership with National AMSA.

When filling this form out, print LEGIBLY

First Name:________________________________________

Last Name:________________________________________

E-Mail Address:____________________________@baylor.edu

Baylor ID (89XXXXXX): __________________

Graduation Year: ________________ Gender: ____________________

Semesters in AMSA:______


DUES AND FEES - (Please check one:)
Dues include LOCAL Membership and benefits for the time desired:
__ $30 for one year __ $55 for two years __ $100 for four years
(Applications will not be accepted without the local membership fee. All returned checks will incur a $10.00 fee plus the
amount owed.)




SIGNATURE:__________________________________________

DATE:_____________________
By signing above, I agree that this payment is non-refundable.

Please turn in this completed application with your check
(payable to: AMSA Baylor) or cash for your premedical
membership to BSB D.108 (Medical Humanities Office in the box
marked AMSA. If you write a check, make sure that your name,
address and a phone number is located on the upper left portion
of the check and is legible.

								
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