PHILIPPINE ASSOCIATION OF MEDICAL TECHNOLOGISTS, INC.

pametcagayan@gmail.com
www.pametinc.ph
MEMBERSHIP INFORMATION FORM
(PLEASE FILL-UP LEGIBLY)
□ NEW □ RENEWAL
PERSONAL INFORMATION

NAME: _______________________ __________________________ ________________________

(Last Name) (First Name) (Middle Name)

Suffix: ______ Profession: ____________ Birthdate: ___________ Sex: _____ Civil Status:________
(Jr. Sr., etc) (RMT, RN, MPH, MSMT, etc.) (YYYY-MM-DD) (M/F) (Single, Married)

SSS: _________________ TIN:__________________ Mobile Number: _______________________

Email Address: __________________________ (Please provide a valid email address for your PAMETWEB member access)

PRC INFORMATION

□I am underage, I have no PRC Information available

PRC No: ____________ PRC Registration Date: ______________ PRC Validity Date:____________
(YYYY-MM-DD) (YYYY-MM-DD)

AFFILIATION (WORK)

Region: __________________ Province: ___________________ City: _______________________

(ex. Region 2) (ex. Cagayan) (ex. Tuguegarao City)

Affiliation: ________________________________________________________________________

HOME ADDRESS

Region: __________________ Province: ___________________ City: _______________________

(ex. Region 2) (ex. Cagayan) (ex. Tuguegarao City)

Complete Address: _________________________________________________________________

HIGHEST EDUCATIONAL ATTAINMENT

Degree: ___________________________ Program/Course:________________________________

You may request for your picture to be taken or you may upload your own picture thru your PAMET WEB
Profile. You may also send your ID picture to our Official FB Page: www.facebook.com/pametcagayan
ID picture submitted must not be stapled on this form; we suggest the use of glue.

I certify that the information contained in this document is complete, accurate, and factual. I understand that
falsifying any of the information in this application form and supporting documents is sufficient found for legal
action and the rejection of my application.

I confirm that I have read, understand and agreed to comply with PAMET’s Constitution and By-Laws, as
evidence by my signature in this application form.

ID Picture ______________________________________________
Signature over Printed Name

(please do not staple)