Application for AMMG Certification: |
| * Category |
|
| * First Name |
|
| * Last Name |
|
| * Academic / Professional Credentials |
|
| * Street Address |
|
| Suite, Apt #, Building#, etc... |
|
| City |
|
| State |
Please use the 2 letters (CT, CA, AR, etc)
|
| Zip |
|
| * Country |
|
| * Phone |
(###) ###-####
|
| * Email |
A valid email address is required for your receipt.
|
| * Password |
Create your personal password here.
|
| How did you hear about our Certification? |
|
Honor / Attestation Statements |
Has a state medical board or other medical oversight committee or organization imposed disciplinary action resulting from a finding or an admission of liability that you violated any professional standard of care, regulation or ethical standard governing the practice of your profession in the past 24 months? |
|
|
Have you been found liable/guilty or entered into settlement that included an admission of liability for professional malpractice, negligence, violation of informed consent, ethical misconduct or other harm to a patient by any criminal court, civil court or court appointed arbitrator in the past 24 months? |
|
|
I understand AMMG’s Certification Policy and Active Certification Policy and agree to abide by provisions governing the use of Certification Logos by graduates
|
|
|
To the best of my knowledge, the information contained in the application is true, complete and correct and is made in good faith. I understand that
information supplied is subject to audit and failure to provide full and accurate information, or to respond to a request for further information, may be sufficient cause for AMMG to bar me from the exam, withhold or revoke certification or take other appropriate action with regard to my certification status. In addition I agree to keep the contents of the exam and study materials confidential and not discuss the content with anyone except authorized AMMG representatives.
|
|
|
|
Certification |
| Total due with Application $5,900 (Two-Payment Option - $3,100 with Application and $3,100 within 60 days but prior to the Module I Exam) |
| * Payment Option |
|
| Certification |
$5,900.00
|
AMMG Membership* Professional 2 year Membership included
|
| AMMG Membership |
|
Payment Information
Please complete the requested information below: |
|
* Payment Method |
|
|
* Name as it appears on card |
|
|
* Credit Card Type |
|
|
* Credit Card Number |
|
|
* Expiration Date |
|
For payment by check please make it payable to AMMG and mail to:
AMMG
1534 Serrano Circle
Naples, FL 34105
USA
|
| |
Total Due Now: $5,900.00 |
| |
|