Application Form

The Caribbean Association of Medical Technologists For Laboratory Professionals APPLICATION FOR MEMBERSHIP

---

Copies of certified Certificates, Diplomas and /or Degrees, passport size photograph, appropriate fee and other supporting evidence must accompany this form

THE APPROPRIATE FEES MUST ALSO BE SUBMITTED: Registration Fee: US$5.00, Annual Fee = US$35.00, Reinstatement Fee: US$85.00, New applicants US$ 40.00(Registration and Application fees) Reinstatement Fee (Reinstatement and Annual Fees) Student Annual Fee: US$ 40.00(Annual and Registration Fees) for the duration of the training program.

Last Name: *

First Name: *

Middle Initial: *

D.O.B: *

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050

Sex: *

Male

Female

Branch: *

Mailing Address: *

Email :

Telephone :