The “Separate but Together” campaign was established as an effort to assist AMA members who have been financially impacted by COVID-19 and are looking for assistance to renew their membership.

Nominator Information (If applicable)

Nominator Name

Nominator Phone Number

Nominator Email Address

Confirm Email Address

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

AMA Number *

AMA Expiration Date (Click the calendar icon to choose your expiration date) * +

Without this assistance I would be unable to renew my AMA membership

*

I have been financially impacted by COVID-19 through *

Loss or change in employment in my immediate family

Costs of illness related to COVID-19

Other (please specify) Other (please specify)