American Medical Student

Association (AMSA)
University of California, Irvine

Thank you for your interest in joining the UCI chapter of the American Medical Student
Association (AMAS). AMSA works hard at creating an environment that welcomes all pre-med
students to talk to one another about their passion and path towards a career in medicine. Your
local membership helps bring speakers, put on social events, provide refreshments for meetings
and support community service activities.

Please complete this form to join UCI – AMSA, a local chapter.

PLEASE TYPE OR PRINT CLEARLY

Today’s Date: _______________ Name (last, first): ____________________________________

Street Address: _________________________________________________________________

City: __________________________ State: ___________ Zip Code: ______________________

Phone ______________ Year in College ______________ Student ID# ____________________

Email Address: _________________________________________________________________

Payment Included is: One Academic Year - $35

Circle payment type: Check Cash

(Checks payable to: AMSA – UCI)

You may submit your application and dues to any chapter officer at regularly scheduled meeting.
If you have any questions or concerns regarding club fee please email the treasurer at
tmatin@uci.edu

You may also mail them to:

American Medical Student Association (undergrad)
Office of the Dean of Students
Irvine, CA 92697
Questions or concerns email Treasurer Taraneh at tmatin@uci.edu, or President Fang at fangj@uci.edu or VP Mital at
patelmr@uci.edu