ONLINE Membership Application

PHILIPPINE ASSOCIATION OF MEDICAL TECHNOLOGISTS, INC.
ONLINE MEMBERSHIP APPLICATION FORM
NOTE: PLEASE FILL-UP LEGIBLY
Unit 1720, 17/F, Cityland 10 Tower 2, Ayala Avenue, North Makati City, Philippines

Please duly accomplish all fields marked with * All REQUIRED Fields

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MEMBERSHIP DETAILS
Please Complete all details for Membership ID CARD Generation
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TYPE (*)

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Please Choose

FEE (*)

NEW Memberhip FEE( 450.00 Pesos)
Membership RENEWAL FEE (350.00 Pesos)

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Membership or RENEWAL Fee

CHAPTER (*)

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Select Chapter

Chapter Name

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* If not in LIST

Pamet ID NO (*)

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*New Members-Use 00000"

Member Since

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Year of First Memberhip

PRC License Number

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Your PRC License Number

PRC Year Issued

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Issued Year of your PRC License Number

PRC Year Valid Until

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Year Date of PRC Validity

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PERSONAL INFORMATION DETAILS
Please Complete all details for Membership ID CARD Generation
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First Name (*)

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Your First Name

Last Name (*)

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Your Last Name

Middle Initial

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Your Middle Initial

GENDER (*)

MALEFEMALE

Please Choose your Gender

Birth Date :: Please Select (Day, Month, Year)

Day (*)

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Day of Birth

Month (*)

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Select Month of Birth

Year (*)

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Year of Birth

Address Information

HOUSE NO. STREET NO. (*)

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HOUSE NO. AND/OR STREET NO.

Street Name (*)

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Street Address

Village Name

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Village Name

Barangay/Subdivision

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Barangay or Subdivision

CITY (*)

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CITY OR MUNICIPALITY

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CONTACT INFORMATION DETAILS
Please Complete all details for Membership ID CARD Generation
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Email (*)

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Your Email Address

EMAIL VERIFICATION

Email Again (*)

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Enter Your Email Address again

Telephone Number

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Your Contact Telephone Number

Fax No.

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Your Fax No.

CELLPHONE No. (*)

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Your Mobile Number

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WORK INFORMATION DETAILS
Please Complete all details for Membership ID CARD Generation
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INSTITUTION / COMPANY (*)

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Institution / Company

Position

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Your Position

Address

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Institution / Company Address

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PAYMENT INFORMATION DETAILS
Please Note on the Bank Account Number for Bank Deposit payments
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Bank Deposit
PNB-GSIS
PAMET ACCOUNT NUMBER
075800092-3
After Wire transfer * Bank Deposits is completed
Please email us a clear copy of your bill payment slips at:
payments@pametinc.org

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FOR MEMBERS ID CARD PRODUCTION
Please UPLOAD A scanned copy of your ID Picture for ID Card Generation
* Please include any additional instructions for your membership id card processing
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UPLOAD ID

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Please upload filetypes .JPG .BMP .GIF .TIFF .PNG only (Maximum of 2MB)

ADDITIONAL INFORMATION & INSTRUCTIONS FOR YOUR MEMBERSHIP ID CARD PRODUCTION

CLAIM ID BY: (*)

I will claim my ID Personally at PAMET Secretariat Office
I will send a representative to pick-up my Membership ID Card (*INPUT Representative Name)

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Your Representative

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Name of Your Representative

Instructions

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Additional Information and Instructions

Please check the best way to contact you (*)

By Telephone# Given
By Email Address Given
By Cellphone # Given

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Choose the most convenient way that we could contact you ... when your MEMBERSHIP ID Card is ready for pickup.

IMPORTANT NOTE:
Falsification of any of the information given in this ONLINE Application form and Other supporting Attached Documents "are sufficient grounds for Legal Action and the rejection" of your Application.

CONFIRMATION (*)

I confirm that I have read, understand and agreed to comply with* PAMET's Constitution and By-Laws, As evidence by my Certification of this ONLINE Membership application form.

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Confirmation

CERTIFY (*)

I Certify, That all the information submitted is complete, accurate and factual.

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Certification of All information

SUBMIT Application

Important NOTE:
ALL SUCCESSFUL ONLINE MEMBERSHIP APPLICATIONS will only be considered as * VALID and for ID Card Production :: when PAYMENT and VERIFICATIONS are COMPLETED

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For More information & Follow up on your applied Membership
Please contact us: PAMET Secretariat