MTA Member Application Form

Organization Name:*

Address:*

Postal Code:*

City:

State:

Country:*

Main Telephone:*

Fax:

Main Email :*

Website:

Applicant Name:*

Applicant Telephone:*

Applicant Email:*

Billing Name:*

Billing Telephone:*

Billing Email:*

Email to receive all
MTA correspondences:*

Please Check the Application Level you are applying for:

Corporate Gold (Includes Premiere Benefits) USD $5,000
Government/Healthcare Cluster/Associations USD $5,000
Hospital USD $3,000
Travel and Hospitality Companies USD $2,000
Specialty Clinic/Dental/Cosmetic/Clinical Trials USD $2,000
Spa and Wellness USD $2,000
Medical Tourism Facilitator USD $1,500
Corporate Membership USD $1,500
Industry Associations and Chambers USD $1,000 *Excludes Hospital Associations
Buyer's Circle USD $500 *Must be Pre-Qualified (200 Limit Annually)
Practicing Physician USD $500 *Must Provide Valid Active License
Nurse and Physician Assistant USD $250 *Must Provide Valid Active License; this category is strictly for professionals without a medical tourism business

	Yes, include me on MTA Directory and MTA Website Listing
	No, exclude me from MTA Directory MTA Website Listing

If for any reason membership cannot be granted then a refund of the membership dues will be sent to the applicant.

Type Above Code :*