AMGO Membership Application Due to technical difficulties forms cannot be electronically submitted at this time. Please print out this form, fill it out, and fax or mail to Ms. Gorman at the fax number / address listed at the bottom of this form. Thank you.
Applicant Information
Name: E-Mail address:
Present Position: How long in this position?
Institution:
Name of Department Chair: E-Mail address:
Address: City: State: Zip Code:
Telephone: Fax Number:
Previous Employment in Health Care Fields:
Inclusive Dates: Title: Department:
Highest Degree Earned:
High School Associate Baccalaureate Master Doctorate Other
Membership Category (see AMGO Brochure or Website for details)
Do you hold the most senior administrative position in your department? Yes No If not, please state his or her name and e-mail address:
Fill in one of the following: Your Department is part of a medical college accredited by the Association of American Medical Colleges (AAMC). School Name: or Your Department is affiliated with or related to an accredited AAMC medical school. School Name: Membership Category Requested: Active Associate A letter requesting membership endorsement will be sent to the Department Chair. If you have been referred to us by an AMGO member, please state their name: Completed applications will be electronically submitted to: Carolyn Gorman Membership Chair, AMGO Department of OB/GYN University of Pennsylvania Health System 5 Dulles 3400 Spruce Street Philadelphia, PA 19104 For more information, please contact Mr. Kirschner at: Telephone: 215-662-7807 Fax: 215-349-5893 email: gormanc@uphs.upenn.edu
Date: