Request to join

Assalamu'alaikum! Thank you for your interest in The American Muslim Physicians Association.

Please fill out this form to gain access to our community. The information provided will only be accessible to admins and verified members.

A photo of your work ID or driver's license must be uploaded for verification purposes.

* Required fields are marked with an asterisk

First name *

Last name *

Personal email (non-institution) *

Current Year of Training / Practice Type *

Current Institution/Practice *

Current Level of Training *

Specialty *

Do you want to be a designated mentor in our mentor directories? *

Personal mobile *

ID (work ID or driver's license) *

Keep this blank

I give consent to the American Muslim Physicians Association to use this information to build a profile when my request is approved and to regulate access to the platform. The ID picture is only used for verification purposes and will not be displayed. *