MEMBERSHIP APPLICATION FORM First Name (*) Last Name Chapter (*) A K M G Emirates Abudhabi Ajman & UAQ Alain Dubai Fujiarah Ras al Khaima Sharjah Emirate (*) Abudhabi Ajman Al ain Dubai Fujairah Ras al Khaima Sharjah UAQ Specialization (*) AKMG Office Secretary Anaesthesiologist & Intensive care specialist Anaesthetist Cardiologist Cardiothoracic Surgeon Consultant Anaesthetist Consultant Cardio Thoracic Surgeon Consultant Endocrinologist Consultant Ophthalmologist Consultant Urologist Dental Surgeon Dermatologist & Cosmetologist Dermatologist & Venerologist Endocrinologist Endodontist & Conservative Dentist ENT Specialist ENT Surgeon Eye Specialist G.P Dentist Gastroenterologist General Physician General Practitioner Gynaecologist & Infertility Specialist Intensivist Medical Specialist Medical Specialist (Internist) Neonatologist Nephrologist Neurologist NeuroSurgeon Neurosurgeon Obstetrician & Gynaecologist Oncologist Oral and Maxillofacial Surgeon Oral Pathologist Orthodontist Orthopaedic Surgeon Paediatric Gastroenterologists Paediatric General Practitioner Paediatric Surgeon Paediatric Urologist Paediatrician Paedodontist Pathologist Periodontist Physical Medicine & Rehabilitation Physician Plastic Surgeon Prosthodontist Psychiatrist Psychologist Radiologist Specialist Anaesthetist Specialist Paediatrician Specialist Physician Specialist Surgeon Urologist Type of Application (*) Ordinary Couple Life Life Couple Associate MOH/DOH Reg #   Personal Details Date of Birth (*)     E-Mail (*) Res Tel Mobile     Login Details User ID (*)   Password (*)           Membership Fees: Ordinary Dhs 200 Couple Dhs 350 Life Dhs 1000 Life Couple Dhs 1500 Associate Dhs 100

Note: 1. Chapter is for AKMG Emirates Chapter and Emirate is for Place of Working/Residence. 2. The detailed member form can be updated after approval. Important Information: 1. The Date Controls work only in Internet Explorer. 2. (*) Indicates the fields are mandatory.