Membership Form

American Nutritional Medical Association Inc.
P.O.Box 66005 Stockton, CA 95206 U.S.A. 

REGISTRATION FORM
 We would prefer type written form for neat entries and would request you to avoid sending hand written forms.

APPLICANT DETAILS (Please fill in BLOCK letters)
Title _____________________________________________________________________
First Name _______________________________________________________________ 
Last Name _______________________________________________________________ 
Institution / Organization ____________________________________________________ 
Mailing Address___________________________________________________________ 
City _____________________________________________________________________
State ___________________________________________________________________
Country _________________________________________________________________

Zip Code ________________________________________________________________ 
Telephone* with STD code _________________________________________________
Fax ____________________________________________________________________
Mobile __________________________________________________________________
Email ___________________________________________________________________
Category               GENERAL LICENSIATE     ASSOCIATE
Members               USD 200    USD 300          USD 200
Students                                                        USD 200        

Life Members         USD 1000   USD 1500       USD 1000
Renewals              USD 250    USD 250          USD 150
Executive Member USD 2000  USD 2000         USD 1500
 

PAYMENT DETAILS

Registration form, completed in all respect along with the registration fee, may be sent to the ANMA secretariat by any of the options below,
1. You can transfer the amount by Wire/Swift transfer in the ANMA Bank account:
• Bank Name: Bank of America
• Accounts name: ANMA
• Account No: 11394-44401
2.Payment could also be made by DD/ Multi-city Cheques/Bank transfer to your nearest IHMS
    authorised Center.  A list of authorised centers may be obtained upon request          http://anmainc.webnode.com/contact-us/
   Please pay the fee through demand draft/credit card.
   Membership would be confirmed subjected to realization of cheque.

• For students, a certificate from the head of department / Institution is compulsory.
• The fee of Executive Members includes Life membership of ANMA.