Group Practice Journal Digital Version Qualification Form

Please fill out this form completely in order to receive either an online version of the Group Practice Journal only, or online and print versions. You do not have to complete this form if you wish to continue receiving your print version only. Note that your e-mail address will be your login and your last name will be your password. Please note that AMGA Medical Group members have complimentary subscriptions to the magazine. Contact Christopher Gibbs at (703) 838-0033, ext. 362 or cgibbs@amga.org  to determine if your organization is a member of AMGA or to add additional individuals from your group to the distribution list.

Group Practice Journal Digital Version Qualification Form
First Name *
Last Name *
Title *
Organization *
Address *
City *
State *
ZIP Code *
E-mail *
The following description best fits my organization:

Clear Selection
If other, please describe.
Title

Clear Selection
If other, please describe.



Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

AMGA | One Prince Street, Alexandria, VA 22314-3318
(703) 838-0033 phone (703) 548-1890 fax
image widget