AMSA

Chartering an AMSA Chapter

APPLICATION TO PETITION THE AMERICAN MEDICAL STUDENT ASSOCIATION TO ESTABLISH AN AFFILIATE PREMEDICAL STUDENT CHAPTER

SCHOOL INFORMATION

* REQUIRED FIELDS
Name of School*:
City*:
State*:
Zip Code*:
AMSA Region:
Total Number of Members:
Date of Fall Term:
Date of Spring Term:
Month of Your Elections:
Charter Expect Date:
Advisor Name (if applicable):
Advisor Phone or Email (if applicable):

We, the chapter officers (listed below), petition the American Medical Student Association (AMSA) to establish at our school an affiliate premedical chapter to be formally recognized by AMSA. We certify that we and our members are enrolled as students at the aforementioned school. We recognize AMSA as a professional national organization designed to address the personal and social concerns of physicians-in-training at any level. Therefore, we are forming this chapter with the intention of upholding AMSA's mission: to offer soon-to-be physicians important non-traditional learning experiences, which will serve to supplement their professional training.

We further certify that the affiliate premedical chapter of AMSA will be established and will function according to the Constitution, Bylaws, Structure, Functions and Internal Policy; and Preamble, Purposes and Principals of AMSA. We finally certify that an appropriate representative at our school has given approval for the establishment of our affiliate premedical chapter of AMSA.

Recognized name of affiliate premedical chapter of AMSA:

"AMSA, (Insert name of school)"

 

LOCAL CHAPTER OFFICERS

Please provide names, addresses and phone numbers for your local chapter officers. Local officers must be members of National AMSA in order to be recognized. Your AMSA ID is a 6-digit number located on your AMSA ID Membership Card or at the top left corner on your mailing label for The New Physician magazine.

President:
Name:
Address:
Phone:
E-mail:
AMSA ID:
Vice President:
Name:
Address:
Phone:
E-mail:
AMSA ID:
Treasurer:
Name:
Address:
Phone:
E-mail:
AMSA ID:
Secretary/Recruitment Coordinator:
Name:
Address:
Phone:
E-mail:
AMSA ID:

 

FIVE (5) ACTIVE STUDENTS AT YOUR SCHOOL

You need at least five (5) premedical students who are national AMSA members at your chapter in order to petition for chapter status. These members can also be your local chapter officers.

The annual dues for AMSA national premedical membership are (all dues in U.S. currency):

  • $75 for up to 5 years of premedical training. $50 annual fee for premedical training taking more than 5 years.

AMSA national annual dues are subject to change – please refer to AMSA's Online Application for the current fee structure.

Member 1:
Name:
Contact information already listed above
Address:
Phone:
E-mail:
AMSA ID:
Member 2:
Name:
Contact information already listed above
Address:
Phone:
E-mail:
AMSA ID:
Member 3:
Name:
Contact information already listed above
Address:
Phone:
E-mail:
AMSA ID:
Member 4:
Name:
Contact information already listed above
Address:
Phone:
E-mail:
AMSA ID:
Member 5:
Name:
Contact information already listed above
Address:
Phone:
E-mail:
AMSA ID:

 

LOCAL CONSTITUTION & BYLAWS

Once you submit this form, you will be asked to email us a copy of your local Constitution & Bylaws. A sample template can be found at online.