Association of Physician Membership Application
Membership types and fees as below
1. Ordinary members (Specialist in internal medicine iM or mmed in any iM discipline): 100,000 Tshs
2. Associate members (Residents in internal medicine and registrars in internal medicine): 50,000 Tshs

INSTRUCTIONS
1. Fill this form - COMPLETELY
2. Payment option

a. BANK TRANSFER
Deposit the fees in a Aphyta Bank Account: 

Name: The Association of Physicians of Tanzania
Bank: NMB
Account Number: 20910032155

b. LIPA Number (tigo)
8829908
See picture below


3. Send the deposit slip (Evidence of transaction) electronically via aphytanzania@gmail.com. Subject should be your name and phone number
4. You should receive an acknowledgment of payment (receipt and membership number)
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Email *
MCT number *
Name [First name, middle and surname] *
Phone number (format to use +255755xxxyyy) *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Year qualified as physician (if physician)
MM
/
DD
/
YYYY
Qualification *
Sub-speciality qualification. write none if you don't have a sub-speciality *
University/College - a list of your colleges and qualification attained may be outlined
Type of Membership being applied *
LIPA number payment
Acknowledgment and Certification
I have filled the form correctly and I hereby certify that the information contained in this application is true, complete, and correct to the best of my knowledge and belief.

I declare to abide by the Constitution of the
Association and uphold APHYTA’s code of conduct

I consent for the publishing of my name as a member of the Association of Physicians in Tanzania
 *
Required
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