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Home
About AMPA
Membership
Membership Renewal
Committees
AMPA Leadership
Position Papers
Medical Director Core Curriculum
AMPA Store
GAMUT
Contact Us
Links
Members
Medical Director’s Toolkit
Password Recovery/New Password Setup
Member Login
Audio File Sharing
CCTMC
Search
Search
AMPA
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Membership Form
Membership Form
AMPA Membership
Name
*
First
Last
Credential
Flight Program/Facility
*
Preferred Mailing Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Phone
International Phone
Fax
Email
*
Select Membership
*
Founding Member - (Physician, Voting) $375
Active Member - (Physician, Voting) $375
Affiliate - (Transport Service, or Non-physician Medical Professional) $150
Medical Student/Resident/Fellow - (Documentation Required) $100
Academic Membership - available to Residency Programs. Please contact the AMPA office at 801-263-2672 for details.
Please complete the following to help AMPA better serve you. Is your transport program (check all that apply)
Rotor Wing
Fixed Wing
Ground
Hospital-Affiliated
Free Standing
For Profit
Not-For-Profit
What is your medical specialty?
Your Position with the transport program:
Medical Director
Flight Physician
Other
Check your Credentials that apply
MD
DO
If you are a Medical Director, how long have you had this position?
How much time weekly do you spend on medical direction?
Is your transport service CAMTS certified?
Yes
No
How did you hear about AMPA? (i.e. colleagues, journal ad, etc.)
What is your motivation to become an AMPA member or to renew your membership?
Comments
This field is for validation purposes and should be left unchanged.