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									Data licensing agreement
Data lists help identify members and nonmembers for your membership efforts. The American Medical Association (AMA) requires a data licensing agreement for your chapter in order to provide you with the data. Once signed, the agreement is active until Dec. 31 of that year. If you are requesting member or nonmember data lists, first complete and submit this form, then contact the AMA Medical Student Section Outreach Program (MSSOP) at or (800) 262-3211. Your name: Your school: Today’s date: ___________________________________________ __________________________________________ ________________________

Information requested: _____________________________________ I, the undersigned, agree to the following conditions regarding use of the American Medical Association Physician Masterfile data:   The AMA data are to be used specifically and only for the purpose of recruiting and retaining members to the American Medical Association. The AMA data represent unique, confidential, and unpublished data and the AMA’s rights including, but not limited to, common law and statutory rights and copyright in such information are not assigned or released as a result of this Agreement, but are at all times reserved and retained by the AMA, subject to the limited use permitted under this Agreement. Neither the AMA data as a whole nor any portion thereof may be published or released to any party whomsover without the prior written approval of the AMA, at its sole discretion. The AMA data are provided “as is” without warranty of any kind as to completeness or accuracy and the AMA is released from any and all liability for inaccurate or incomplete information contained in the AMA data. The AMA shall deliver to the undersigned the referenced AMA data after receipt of this Agreement signed by the undersigned.

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Signature: ________________________________________________ Date: ______________ E-mail address: ____________________________________________

Please send this completed form to: American Medical Association MSSOP 515 N. State St., 9th floor Chicago, IL 60610 Fax: (312) 464-5838

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