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IAMRA Membership Application

If you wish to become an IAMRA member, you must complete an application. For online registration, please complete the information below.  If you prefer, you may download and print the registration form.

Note: Your email address will be used for IAMRA purposes only.

Any fields with * are required.

Organization: *
Department:
Division:
Address 1:*
Address 2:
City:*
Country:*
State or Province:
Zip OR Postal Code:
Name of CEO:*
Title of CEO:*
Phone Number:
Fax Number:
Email:
Organization Web Site:
Person to whom all communications from IAMRA Secretariat should be sent, if different from above:
Contact First Name: *
Contact Last Name: *
Title: *
Email Address: *
Phone Number: *
Fax Number:

 

If applying for full membership, please provide a general description of the following in the space below:

  1. Describe the legal authority (provincial, federal, or state laws) by which your organization has received its regulatory powers.

  2. Describe your organizational structure (e.g., government agency or self-regulatory body, etc).

  3. Which regulatory services are provided (licensure, discipline, education, specialist certification, continuing competence, physician health, etc)?

  4. To what staff or office should information on disciplinary actions be sent?
If applying for Partner Membership, check here and provide information about your organization that is pertinent to medical regulation.
   

Organization Description: *

                                       

If you are currently a member of IAMRA and wish to update your International Directory information, please log into the Members Only section.

For assistance, please contact Roxanne Huff at secretariat@iamra.com or call 817-868-4006
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