By submitting this form, I understand and agree to terms and conditions stated below.

MEMBERSHIP APPLICATION DISCLAIMER , ACKNOWLEDGEMENT AND WAIVER.

I hereby certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing membership, or for discharge should I be accepted membership. I hereby authorize any of the persons or organizations listed in my application to give all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application, and release all such parties from all liability that may result from furnishing such information to you. I also authorize you to request and receive such information. In consideration for my membership, I agree to abide by the rules , regulations , procedures and protocols of the company (Myanmar Multispecialty Physicians Global Alliance) which rules may be changed, withdrawn, added or interpreted at any time at the company's sole option and without prior notice to me. I also acknowledge that I need to submit two letters of recommendation from current MMPGA members (can by via email). I also give MMPGA permission for my personally identifiable information and photos/images to be published in MMPGA web page. I also acknowledge that my membership may be terminated, or any offer or acceptance of membership withdrawn, at any time, with or without cause, and with or without prior notice at the option of the company or myself. I also agree to pay non-refundable membership fees of US$ 200. I also acknowledge that to become a full member, a physician must have at least 2 years of active independent practice in respective discipline (Internal Medicine or Family Medicine or Pediatrics or General Surgery) after finishing post-graduate training and MMPGA can consider full membership eligibility on a case by case basis.