PHILIPPINE ASSOCIATION OF MEDICAL TECHNOLOGISTS, INC.

Unit 1720 17/F, Cityland 10 Tower 2, Ayala Avenue, Makati City

www.pametinc.ph

MEMBERSHIP INFORMATION FORM

(PLEASE FILL-UP LEGIBLY)
PERSONAL INFORMATION NEW MEMBER FOR RENEWAL/PAMET ID:
NAME: _____________________________ _________________________________ _______________________
(Last Name) (First Name) (Middle Name)

SUFFIX: ___ PROFESSION:__________BIRTHDATE:_____________ SEX: ___ CIVIL STATUS: ________

(Jr, Sr, etc) (RMT, RN, MD, Etc) (ex: July 21, 1982) (M/F) (Single/Married)

SSS:_______________________ TIN: ____________________ MOBILE NUMBER:________________________________

EMAIL ADDRESS:___________________________________ (Please provide a valid email address for your PAMETWEB member access)

PRC No:________________ PRC REGISTRATION DATE: ________________ PRC VALIDITY DATE: _______________

REGION:_________________ PROVINCE: _________________________________ CITY:__________________________

(ex: Region XI) (ex: Davao Del Sur) (ex: Davao City)

AFFILIATION:_________________________________________________________________________________________

REGION:___________________ PROVINCE: ___________________________ CITY:__________________________

(ex: Region XI) (ex: Davao Del Sur) (ex: Davao City)

ADDRESS:
_______________________________________________________________________________________________

DEGREE:______________________________________________________
PROGRAM:____________________________________________________

You may request for your picture to be taken or you may upload your own picture thru your PAMET WEB Account.

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 ground for legal action and the rejection of my
application.

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