Online Membership Application Form
Membership is open to to all Physicians, Dentists and other medical personnel associated with and interested in medical practices and the welfare of Liberia and Liberians including, but not limited to nurses, anesthetists, physicians assistants, respiratory technologists.

Please take  a few minutes to fill out the below form and click the submit at the very end of the form when done. Sections with asterisks are required.

Dues:$250.00/yr for physicians in clinical practice
          $100.00/yr for all other categories

First Name *
Last Name *
Phone number *
E-mail *
Mailing Address
City *
State/Country *
Zip code *
I am a *
If "other" above please specify
Medical School/School attended 
Address of school attended
Year graduated
Postgraduate training(include institution)
Which committee(s) are you interested in joining? 
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Membership Dues Payment
Below are options for dues payment. Please check an option, submit the form and then pay by chosen option.
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