Membership Application Form

Association of General Practitioners of Jamaica

Thank you for your interest in joining AGPJ. Please complete the form below. Fields marked with an asterisk () are required.*

PERSONAL INFORMATION

Full Name:

First Name:

Last Name:

Address:

Street Address:

City/Town:

Parish:

Country:

Email Address

Telephone Number

PROFESSIONAL DETAILS

Medical Qualifications (Please list your qualifications below)

Current Practice Status

Full-Time General / Family Practice Part-Time General / Family Practice

Current Position / Occupation:

Parish of Practice:

AREAS OF INTEREST

Medical Interests:

Non-Medical Interests:

MEMBER INVOLVEMENT & VOLUNTEERING

In which areas would you be willing to serve AGPJ? (You may select more than one

Administration Community Service Continuing Medical Education (CME) Event / Workshop / Conference Planning Membership & Mentorship Primary Care Research Advocacy Fundraising / Finance Newsletter / Publications Social Media & Communications Sponsorship Committee Website / Digital Support Nomination & Election Committee Executive Leadership Organising CME Activities Other:

SUPPORTING DOCUMENTS

Please upload the following documents:

Curriculum Vitae (CV) Passport-size photograph Medical diplomas / certificates

📎 Upload files here (PDF, JPG, or DOC formats accepted)

Max 10 MB

MEMBERSHIP FEES

Annual Membership Subscription:

• AGPJ Membership Fee: JA$5,000.00 >> PAY NOW <<

• Children’s Home Support Contribution: JA$1,000.00 (annually) >> PAY NOW <<

Total Payable:JA$6,000.00

PAYMENT CONFIRMATION

Payment Declaration

I confirm that I have made the required payment

DECLARATION

I confirm that the information provided in this application is accurate and complete to the best of my knowledge.

Thank you for applying to become a member of AGPJ.

Once your application and payment are verified, we will provide your with your New Member package.

Leave this field empty