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.