Enrollment FormEnrollment Form*First NameFirst Name can not be left blank.Please enter valid data.This first name is invalid. Please enter a valid first name.*Last NameLast Name can not be left blank.Please enter valid data.This last name is invalid. Please enter a valid last name.*Primary DegreePrimary DegreeSelect OptionDegreeBDSDDSDOMBBSMDMDSMPHMSPhDMBAJDPlease select atleast one option.Please enter valid data.*Primary SpecialtyPrimary SpecialtySelect OptionAddiction MedicineAerospace MedicineAnesthesiologyCardiac surgeryCardiovascular DiseasesChild PsychiatryChiropracticColon & Rectal SurgeryCritical Care (Intensivists)DentistDermatologyDiagnostic RadiologyEmergency MedicineEndocrinologyFamily MedicineForensic MedicineGastroenterologyGeneral PracticeGeneral SurgeryGeriatric MedicineGynecological oncologyGynecologyHand surgeryHematologyHematology/OncologyHospitalistHospitalistInfectious diseaseInternal MedicineMaxillofacial surgeryMedical OncologyNeonatologyNephrologyNeurological SurgeryNeurologyNeuropsychiatryNeuro-RadiologyNeurosurgeryNuclear MedicineObstetrics & GynecologyOccupational MedicineOphthalmologyOptometryOral surgeryOrthopedic SurgeryOther SpecialtyOtolaryngologyPain ManagementPalliative CarePathologyPediatric CardiologyPediatric EndocrinologyPediatric Hematology/OncologyPediatric NephrologyPediatric RadiologyPediatric SurgeonPhysical Medicine & RehabilitationPlastic SurgeryPodiatryPsychiatryPublic HealthPulmonary DiseasesPulmonary/Critical CareRadiation OncologyRadiology InterventionalReconstructive surgeryRehabilitation MedicineRheumatologySleep MedicineSports MedicineSurgical oncologyThoracic SurgeryTransplant SurgeryUndecidedUrologyVascular SurgeryFamily Medicine/Family PracticeAllergy & ImmunologyCritical Care SurgeryTrauma SurgeryEndocrinology, Nuclear MedicineGynecology, Obstetrics & GynecologyColon & Rectal SurgeryColon & Rectal SurgeryCytopathologyAnesthesiology, Pain ManagementInternal Medicine, Family MedicineRadiologyPulmonary Diseases, Critical Care (Intensivists)Internal Medicine, Geriatric MedicineGeriatric Medicine, Sleep MedicineSleep Medicine, Internal MedicineHospice & Palliative MedicineHospice & Palliative Medicine (Emergency Medicine)Epilepsy & NeurophysiologyInfectious Disease MedicineDevelopmental-Behavioral PediatricsOncologyAnatomic & Clinical PathologySurgeryObstetrics & Gynecology, Forensic MedicineEmergency Medicine, Geriatric MedicineNeonatal MedicineReproductive Endocrinology & InfertilityGynecologic SurgeryChild & Adolescent PsychiatryGeneral Medicine, PediatricsInternal Medicine, Nuclear MedicineHematology/Oncology, Palliative CareEmergency Medicine, General SurgeryPreventive Occupational MedicinePhlebologyEar, Nose, and ThroatCardiologyCritical Care (Intensivists), Sleep MedicineNuclear RadiologyGeriatric Medicine, Internal MedicineFamily Medicine, GynecologyDiagnostic Radiology, Nuclear MedicineCosmetic SurgeryInternal Medicine, OncologySleep Medicine, Nuclear MedicinePain MedicineOncology, Internal MedicineGeneral Surgery, Family MedicinePalliative Care, Internal MedicineIndependent Medical ExaminerOrthopedic Hand Surgery, Plastic Surgery of the HandInternal Medicine, HematologyInternal Medicine, Critical Care (Intensivists)Endocrinology, Diabetes & MetabolismUndersea & Hyperbaric MedicineFamily Medicine, Geriatric MedicineCritical Care MedicinePulmonary Disease, Sleep MedicineMedical Oncology, HematologyEmergency Medicine, PediatricsPain Management, Critical Care (Intensivists)Vascular & Interventional RadiologyInterventional CardiologyPain Management, Addiction MedicineNuclear Medicine, Occupational MedicineBariatric SurgeryVascular Surgery, Colon & Rectal SurgeryPulmonary/Critical Care, Internal MedicineInternal Medicine, Interventional CardiologyPediatric NeurologyTransplant HepatologyPulmonary/Critical Care, Sleep MedicineInternal Medicine, Medical OncologyInternal Medicine, Pain ManagementHematology & OncologyClinical Cardiac ElectrophysiologyGeneral Practice, Internal MedicineGeriatric Medicine, Palliative CareCardiovascular & Pulmonary DiseasesPulmonary DiseaseNeurological Movement DisordersPediatric Critical Care MedicineCardiovascular Diseases, Internal MedicinePediatric Hematology/Oncology, PediatricsInternal Medicine, Cardiovascular DiseasesPain Management, Palliative Care, Public HealthCardiovascular Interventional TechnologyTransplant Surgery, Internal MedicineCritical careSleep Medicine, Pulmonary DiseasesGeneral Medicine, Geriatric MedicineGeriatric Medicine, Critical Care (Intensivists)Pain Management, Sleep MedicineAddiction Medicine, Pain ManagementCosmetic & Reconstructive Surgery, General SurgeryPediatric NeurosurgeryAnterior Segment Ophthalmology, Cornea & External DiseasesRheumatology, Geriatric MedicineBreast SurgeryBreast Oncology, General SurgeryPediatrics, Pulmonary DiseasesDentistryTransplant Surgery, Surgical oncologyNeurotology, Otolaryngic Allergy, Sinus SurgerySleep Medicine, Palliative CareAdult & Adolescent Psychiatry, Geriatric PsychiatryInternal Medicine, Pulmonary DiseaseInternal Medicine, Transplant NephrologyOther Specialty, HematologyOrthodonticsPediatric OphthalmologyPsychiatry, Sleep MedicinePediatric Surgeon, Public HealthHospitalist, Internal MedicineOncology, Colon & Rectal SurgeryAddiction Medicine, Geriatric MedicineInfectious disease, Internal MedicineMaternal-Fetal MedicineCardiothoracic SurgeryPulmonary Diseases, Sleep MedicineCritical Care (Intensivists), Pulmonary DiseasesHematology/Oncology, Internal MedicineNephrology, Internal MedicineHospitalist, Infectious diseaseNeuropsychiatry, Public HealthSports Medicine, Reconstructive surgeryDiagnostic Radiology, Radiology InterventionalCritical Care (Intensivists), Infectious diseaseFamily Medicine, Emergency MedicinePublic Health, Palliative Care, Geriatric MedicineGeneral Surgery, Colon & Rectal SurgeryCardiac surgery, Thoracic SurgerySurgical oncology, Urology, Plastic SurgeryInternal Medicine, HospitalistFamily Medicine, HospitalistHematology, Medical OncologyDentist, Oral surgery, Other SpecialtyUrology, Alternative Medicine, Addiction MedicineCritical Care (Intensivists), Pulmonary/Critical CareEndocrinology, Medical OncologyAnesthesiology, PediatricsPulmonary Diseases, Internal MedicineHospitalist, Palliative CareFamily Medicine, Palliative CarePlastic Surgery, Sleep MedicineSurgical oncology, General SurgeryInternal Medicine, Emergency MedicineTransplant Surgery, General SurgeryHospitalist, Cardiovascular DiseasesNeonatolotyTransplant nephrologyIntermal MedicineRadiation OnclogyUrogynecologyPediatrics Critical CareHospital MedicineMedicineInfertious DiseaseProfessorPlease select atleast one option.Please enter valid data.Is your Spouse a Doctor?Is your Spouse a Doctor?YesNoPlease select atleast one option.Please enter valid data.Spouse First NameText field can not be left blank.Please enter valid data.Spouse Last NameText field can not be left blank.Please enter valid data.Spouse Primary DegreeSpouse Primary DegreeSelect OptionDegreeBDSDDSDOMBBSMDMDSMPHMSPhDMBAJDPlease select atleast one option.Please enter valid data.Spouse Primary SpecialtySpouse Primary SpecialtySelect OptionAddiction MedicineAerospace MedicineAnesthesiologyCardiac surgeryCardiovascular DiseasesChild PsychiatryChiropracticColon & Rectal SurgeryCritical Care (Intensivists)DentistDermatologyDiagnostic RadiologyEmergency MedicineEndocrinologyFamily MedicineForensic MedicineGastroenterologyGeneral PracticeGeneral SurgeryGeriatric MedicineGynecological oncologyGynecologyHand surgeryHematologyHematology/OncologyHospitalistHospitalistInfectious diseaseInternal MedicineMaxillofacial surgeryMedical OncologyNeonatologyNephrologyNeurological SurgeryNeurologyNeuropsychiatryNeuro-RadiologyNeurosurgeryNuclear MedicineObstetrics & GynecologyOccupational MedicineOphthalmologyOptometryOral surgeryOrthopedic SurgeryOther SpecialtyOtolaryngologyPain ManagementPalliative CarePathologyPediatric CardiologyPediatric EndocrinologyPediatric Hematology/OncologyPediatric NephrologyPediatric RadiologyPediatric SurgeonPhysical Medicine & RehabilitationPlastic SurgeryPodiatryPsychiatryPublic HealthPulmonary DiseasesPulmonary/Critical CareRadiation OncologyRadiology InterventionalReconstructive surgeryRehabilitation MedicineRheumatologySleep MedicineSports MedicineSurgical oncologyThoracic SurgeryTransplant SurgeryUndecidedUrologyVascular SurgeryFamily Medicine/Family PracticeAllergy & ImmunologyCritical Care SurgeryTrauma SurgeryEndocrinology, Nuclear MedicineGynecology, Obstetrics & GynecologyColon & Rectal SurgeryColon & Rectal SurgeryCytopathologyAnesthesiology, Pain ManagementInternal Medicine, Family MedicineRadiologyPulmonary Diseases, Critical Care (Intensivists)Internal Medicine, Geriatric MedicineGeriatric Medicine, Sleep MedicineSleep Medicine, Internal MedicineHospice & Palliative MedicineHospice & Palliative Medicine (Emergency Medicine)Epilepsy & NeurophysiologyInfectious Disease MedicineDevelopmental-Behavioral PediatricsOncologyAnatomic & Clinical PathologySurgeryObstetrics & Gynecology, Forensic MedicineEmergency Medicine, Geriatric MedicineNeonatal MedicineReproductive Endocrinology & InfertilityGynecologic SurgeryChild & Adolescent PsychiatryGeneral Medicine, PediatricsInternal Medicine, Nuclear MedicineHematology/Oncology, Palliative CareEmergency Medicine, General SurgeryPreventive Occupational MedicinePhlebologyEar, Nose, and ThroatCardiologyCritical Care (Intensivists), Sleep MedicineNuclear RadiologyGeriatric Medicine, Internal MedicineFamily Medicine, GynecologyDiagnostic Radiology, Nuclear MedicineCosmetic SurgeryInternal Medicine, OncologySleep Medicine, Nuclear MedicinePain MedicineOncology, Internal MedicineGeneral Surgery, Family MedicinePalliative Care, Internal MedicineIndependent Medical ExaminerOrthopedic Hand Surgery, Plastic Surgery of the HandInternal Medicine, HematologyInternal Medicine, Critical Care (Intensivists)Endocrinology, Diabetes & MetabolismUndersea & Hyperbaric MedicineFamily Medicine, Geriatric MedicineCritical Care MedicinePulmonary Disease, Sleep MedicineMedical Oncology, HematologyEmergency Medicine, PediatricsPain Management, Critical Care (Intensivists)Vascular & Interventional RadiologyInterventional CardiologyPain Management, Addiction MedicineNuclear Medicine, Occupational MedicineBariatric SurgeryVascular Surgery, Colon & Rectal SurgeryPulmonary/Critical Care, Internal MedicineInternal Medicine, Interventional CardiologyPediatric NeurologyTransplant HepatologyPulmonary/Critical Care, Sleep MedicineInternal Medicine, Medical OncologyInternal Medicine, Pain ManagementHematology & OncologyClinical Cardiac ElectrophysiologyGeneral Practice, Internal MedicineGeriatric Medicine, Palliative CareCardiovascular & Pulmonary DiseasesPulmonary DiseaseNeurological Movement DisordersPediatric Critical Care MedicineCardiovascular Diseases, Internal MedicinePediatric Hematology/Oncology, PediatricsInternal Medicine, Cardiovascular DiseasesPain Management, Palliative Care, Public HealthCardiovascular Interventional TechnologyTransplant Surgery, Internal MedicineCritical careSleep Medicine, Pulmonary DiseasesGeneral Medicine, Geriatric MedicineGeriatric Medicine, Critical Care (Intensivists)Pain Management, Sleep MedicineAddiction Medicine, Pain ManagementCosmetic & Reconstructive Surgery, General SurgeryPediatric NeurosurgeryAnterior Segment Ophthalmology, Cornea & External DiseasesRheumatology, Geriatric MedicineBreast SurgeryBreast Oncology, General SurgeryPediatrics, Pulmonary DiseasesDentistryTransplant Surgery, Surgical oncologyNeurotology, Otolaryngic Allergy, Sinus SurgerySleep Medicine, Palliative CareAdult & Adolescent Psychiatry, Geriatric PsychiatryInternal Medicine, Pulmonary DiseaseInternal Medicine, Transplant NephrologyOther Specialty, HematologyOrthodonticsPediatric OphthalmologyPsychiatry, Sleep MedicinePediatric Surgeon, Public HealthHospitalist, Internal MedicineOncology, Colon & Rectal SurgeryAddiction Medicine, Geriatric MedicineInfectious disease, Internal MedicineMaternal-Fetal MedicineCardiothoracic SurgeryPulmonary Diseases, Sleep MedicineCritical Care (Intensivists), Pulmonary DiseasesHematology/Oncology, Internal MedicineNephrology, Internal MedicineHospitalist, Infectious diseaseNeuropsychiatry, Public HealthSports Medicine, Reconstructive surgeryDiagnostic Radiology, Radiology InterventionalCritical Care (Intensivists), Infectious diseaseFamily Medicine, Emergency MedicinePublic Health, Palliative Care, Geriatric MedicineGeneral Surgery, Colon & Rectal SurgeryCardiac surgery, Thoracic SurgerySurgical oncology, Urology, Plastic SurgeryInternal Medicine, HospitalistFamily Medicine, HospitalistHematology, Medical OncologyDentist, Oral surgery, Other SpecialtyUrology, Alternative Medicine, Addiction MedicineCritical Care (Intensivists), Pulmonary/Critical CareEndocrinology, Medical OncologyAnesthesiology, PediatricsPulmonary Diseases, Internal MedicineHospitalist, Palliative CareFamily Medicine, Palliative CarePlastic Surgery, Sleep MedicineSurgical oncology, General SurgeryInternal Medicine, Emergency MedicineTransplant Surgery, General SurgeryHospitalist, Cardiovascular DiseasesNeonatolotyTransplant nephrologyIntermal MedicineRadiation OnclogyUrogynecologyPediatrics Critical CareHospital MedicineMedicineInfertious DiseaseProfessorPlease select atleast one option.Please enter valid data.*Email AddressEmail Address can not be left blank.Please enter valid email address.Please enter valid email address.This email is already registered, please choose another one.*UsernameUsername can not be left blank.Please enter valid data.This username is already registered, please choose another one.This username is invalid. Please enter a valid username.*PasswordPassword can not be left blank.Please enter valid data.Please enter at least 6 characters.Strength: Very Weak*Confirm PasswordConfirm Password can not be left blank.Passwords don't match. Passwords don't match.Address *Address TypeAddress TypeSelect OptionMailingBillingOtherPlease select atleast one option.Please enter valid data.*Residential AddressText field can not be left blank.Please enter valid data.*Address typeAddress typeSelect OptionMailingBillingOthersPlease select atleast one option.Please enter valid data.*Business AddressText field can not be left blank.Please enter valid data.*CityText field can not be left blank.Please enter valid data.*StateText field can not be left blank.Please enter valid data.Please enter valid data.*ZipcodeText field can not be left blank.Please enter valid data.Phone *Phone TypePhone TypeSelect OptionCellFaxHomeHome OfficeOfficeOffice 2PagerPlease select atleast one option.Please enter valid data.*Phone NumberText field can not be left blank.Please enter valid detail.Please enter valid detail.Education *Medical School NameText field can not be left blank.Please enter valid data.Please enter valid data.You are interested in becoming a GWAPI member to be more involved in Social Events/ NetworkingFamily EventsEducational EventsMedical LobbyingAngel Investing and CollaborationAll of the abovePlease check atleast one option.Please enter valid data.cropSkip(Use Cropper to set image and use mouse scroller for zoom image.) Annual Membership Per Couple$200.004 Annual Social Events Monthly Medical Forum Mentorship Program Networking EventMedical Students$100.00Members & ResidentsSelect Your Payment GatewayPaypalHow you want to pay? Auto Debit Payment Manual PaymentPayment SummaryYour currently selected plan : , Plan Amount : , Final Payable Amount: Submit