Student Membership Ambassador Form

1. Date (MM/DD/YYYY) This question requires a valid date format of MM/DD/YYYY.

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2. AAFP ID# *
You must be an AAFP member in order to apply to serve as your FMIG’s Student Membership Ambassador This question requires a valid number format.

3. Address
Student Membership Ambassador materials may be mailed to this address unless otherwise notified

First Name

Last Name

Street Address 1

Street Address 2

Postal / Zip Code

City

State / Province

Country

Email Address

Phone Number

Medical School

Graduation Date (MM/DD/YYYY) This question requires a valid date format of MM/DD/YYYY.

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FMIG Advisor

Why do you feel you are the best candidate for this role?