examapp.agemed.orgAMMG Exam | Application

Toggle navigation Register Login Application for AMMG Certification: * Category Physician Healthcare Professional (non-MD, DO) * First Name * Last Name * Academic / Professional Credentials * Street Address Suite, Apt #, Building#, etc... City State Please use the 2 letters (CT, CA, AR, etc) Zip * Country United States Afghanistan Albania Algeria Andorra Angola Anguilla Antarctica Antigua Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herz Botswana Bouvet Island Brazil Brunei Darussala Bulgaria Burkina Faso Burundi BVI Cambodia Cameroon Canada Cape Verde Cayman Islands Cent African Rep Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D Ivoire Croatia Cuba Cyprus Czech Republic Dem Rep of Congo Denmark Djibouti Dominica Dominican Rep East Timor Ecuador Egypt El Salvador Eq Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Nambia Nauru Nepal Neth Antilles Netherlands New Caledonia New Zealand Nicaragua Niger Niue Norfolk Island North Korea Northern Mariana Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Qatar Reunion Romania Russian Fed Rwanda Saint Lucia Samoa San Marino Sao Tome Saudi Arabia Senegal Serbia and Monte Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia Is South Korea Spain Sri Lanka St Helena St Kitts Nevis St Pierre St Vincent Sudan Suriname Svalbard Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad Tobago Tunisia Turkey Turkmenistan Turks and Caicos Tuvalu UAE Uganda Ukraine United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis Islands Western Sahara Yemen Zambia Zimbabwe * Phone (###) ###-#### * Email A valid email address is required for your receipt. * Password Create your personal password here. How did you hear about our Certification? Honor / Attestation Statements Has a state medical board or other medical oversight committee or organization imposed disciplinary action resulting from a finding or an admission of liability that you violated any professional standard of care, regulation or ethical standard governing the practice of your profession in the past 24 months? No Yes Have you been found liable/guilty or entered into settlement that included an admission of liability for professional malpractice, negligence, violation of informed consent, ethical misconduct or other harm to a patient by any criminal court, civil court or court appointed arbitrator in the past 24 months? No Yes I understand AMMG’s Certification Policy and Active Certification Policy and agree to abide by provisions governing the use of Certification Logos by graduates I Agree To the best of my knowledge, the information contained in the application is true, complete and correct and is made in good faith. I understand that information supplied is subject to audit and failure to provide full and accurate information, or to respond to a request for further information, may be sufficient cause for AMMG to bar me from the exam, withhold or revoke certification or take other appropriate action with regard to my certification status. In addition I agree to keep the contents of the exam and study materials confidential and not discuss the content with anyone except authorized AMMG representatives. I Agree Certification Total due with Application $5,900 (Two-Payment Option - $3,100 with Application and $3,100 within 60 days but prior to the Module I Exam) * Payment Option 2 Payments 1 Payment Certification $5,900.00 AMMG Membership * Professional 2 year Membership included AMMG Membership Lifetime Membership $1,500.00 Payment Information Please complete the requested information below: * Payment Method Credit Card Check * Name as it appears on card * Credit Card Type AMEX Master Card VISA * Credit Card Number * Expiration Date For payment by check please make it payable to AMMG and mail to: AMMG 1534 Serrano Circle Naples, FL 34105 USA Total Due Now: $5,900.00 For assistance with registration please call (239) 330-7495 or email certification@agemed.org Test brought to you by:...