AAGL MEMBERSHIP APPLICATION

    Note: If you are already a member of AAGL, click here to sign in and renew your membership.


Step 1: Select Membership Type

Select your membership type: *  

Step 2: Annual Fees

Please select one of the following membership types. All Fees are listed in USD.
Practicing Physician $375 Retired Physician $175

Your membership includes a $25.00 donation to support the activities of the Foundation of the AAGL. If you do not wish to make a donation to the Foundation, please check the box at left.

Step 3: Provide Us With Your Contact Details

First Name *
Middle Name
Last Name *
Suffix (II, III, Jr.)
Degrees (M.D., FACOG, R.N.)

Gender: * Female  Male Birth Date: *

Please enter your mailing address below. This information will be used in the AAGL Physician Finder to refer patients to your practice:
 
Hospital/Institution:
Address (Line 1):
Address (Line 2):
City:
State:
Province:
Postal Code:
Country:
Telephone:
Fax:
Email:
Re-type Email:
Select Your AAGL Password:
Re-type AAGL Password: