Pls. Accomplish in duplicate:
Original -Dr. JPRMA Organizing Committee
The above nominee is a licensed physician and a member of the Philippine Medical Association with PRC Number 44609 issued on 09-17-1975 and expiring on January 31, 2020.
The nominee is an a member of good standing since 1981 and holds a PMA card number D-1-4576 which expires on (LIFE TIME MEMBER)
Community Leadership Clinical Practice
Government Service √√Academe Research
__________________________________________
(Signature over printed name)
President, PMA Component Medical Society
_________________________________________________________
(Signature over printed name)
President, Specialty Division, Specialty and Affiliate Society
ROJ@19nov8