Membership Renewal Form | Faddishbuilder

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

MEMBER INFORMATION

Full Name

First Name:

Last Name:

Email Address:

Telephone Number:

Medical Council of Jamaica Registration Number:

WORK / PRACTICE ADDRESS

Work Address:

Street / Facility Name:

City / Town:

Parish

Country:

MEMBERSHIP CATEGORY (Select ONE)

Full / Active Member (up to 75 years) – JA$6,000.00 Partially Retired / Semi-Retired Member (76 years and over) – JA$4,000.00 Associate Member – JA$5,000.00 Emeritus / Honorary Member – JA$4,500.00 Intern / Resident / SHO – JA$4,000.00 Medical Student – No Fee (Up to internship) Specialist / Consultant – JA$6,500.00 Affiliate Member (Allied Health Professional) – JA$3,500.00

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CHILDREN’S HOME & OUTREACH SUPPORT

Annual Children’s Home / Outreach Contribution:

Yes – JA$2,500.00 No

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Amount Being Paid for Children’s Home Support (if applicable): JA$

PAYMENT DETAILS

Membership Year Being Paid For:

Total Amount Paid: JA$

PROOF OF PAYMENT (📎 Please upload your payment receipt)

Max 10 MB per file

PAYMENT CONFIRMATION

Payment Declaration

I confirm that I have completed payment for my AGPJ membership renewal and have uploaded the correct proof of payment.

DECLARATION

I confirm that the information provided above is accurate and up to date.

Thank you for renewing your membership with AGPJ.

Your continued support helps strengthen primary care, advocacy, education, and community outreach across Jamaica.