General Membership Application

You may choose any of the following options:

1) Print this form and fill it out offline.
2) Fill it out online, print it and FAX it to us at 562 799-3355
3) Mail it to 1945 Palo Verde Ave. Suite 202, Long Beach, CA 90815-3445.
4) Complete the application process online and use the "Submit" button at the bottom of this page.

*Name*
*Title*
*Organization*
*Address*
*Suite*
*City*
*State/Province*
*Zip code*
*Work Phone*
*FAX*
*E-mail*	*Required to receive lower Internet Membership Dues*
*URL*
*Home Phone*
*Home FAX*

Above address is:		Home	Office
*Date of birth*	Age	Male	Female

Degree / Designation	Profession
M.D. D.O. D.D.S., D.M.D. Ph.D. Psy.D. D.C. O.D. LCSW LPC MA RN CEAP CADC LVN LPT CNA CEO	Physician -- Specialty Psychologist Dentist Chiropractor Optometrist Social Worker Marriage/Family Therapist Licensed Professional Counselor Nurse Employee Assistance Professional Chemical Dependency Counselor MCO Management Staff MCO Case Manager MCO Professional Staff Other Healthcare Provider Allied Licensed Professional Other Non-licensed Professional

Institution Awarding Highest Degree	Date

Additional information:

By submitting this form, I attest that all of the information in this application is accurate and truthful.
I understand that willful falsification or failure to disclose pertinent information constitutes grounds
for denial or subsequent forfeiture of membership and Diplomate status. Submission of this form
authorizes the Academy of Managed Care Providers to verify information provided in this application.

Please provide the following billing information:

Credit card
Amount Authorized
Cardholder name
Card number
Expiration date