Become a Member

AMPIUSA MEMBERSHIP

Personal Detail

First Name *

Middle Name

Last Name *

Date of Birth *

Phone

Mobile *

Address

Street Address

Apt, Suite, Bldg. (optional)

City

Postal / Zip Code

State / Province / Region

Other Info

Profession *

Name of Institute if Student

What services could you provide in the clinic(s) in India? *

Would you like to be contacted for AMPI planning meetings? * YesNo

Would you like to volunteer in the clinic(s) in India? * YesNo

The group American Muslim Physicians of Indian Origin (AMPI) formed in 2007-2008 has the goal of ameliorating these health care needs.