Fulfillment Request Form

Fulfillment Request Form

The Medical Student Outreach Program is proud to support your recruitment efforts. Fulfillment requests must be made at least 21 business days in advance. Once your request is received, please allow our team 5 business days to process your request. Fulfillment will be at the discretion of the American Medical Association.
First Name *
Last Name *
School Email Address *
For order confirmation and tracking information
School Name *
Who is your Field Student Recruitment Manager? *

Emily Ferron Meredith Friedberg
Event Name *
Event Type *

Recruitment Engagement Community / Social Service COVID-19 Related Project
Have you applied for grant funding for this event? *

Yes No
Is this request related to an AMA guest speaker event? *

Yes No
Describe your event and intended use for promotional items *
What is the anticipated attendance? *
When is your event? *

Month Day Year
Actual date of event.
When do the items need to be received by? *

Month Day Year
What Promotional Items would you be interested in receiving? Please note: quantities may be limited and requests are not guaranteed. Please limit your request to a maximum of three items. *

AMA Member Pin (Members Only) Stethoscope Lapel Pins AMA x Headspace Promo Cards AMA Cooling Towel Softwrite Ball Point Pen (AMA) AMA Water Bottle AMA Bluelight Glasses AMA Hand Sanitizer
Do you need an AMA Table Runner? *

Yes No
Delivery information - Recipient *

First Name Last Name
Address line 1 *
Address line 2
City *
State / province *
Postal / zip code *
What is your delivery address? - old, don't use, this is hidden *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
www.ama-assn.org/msop-resource-center

Processing times may be delayed. Please allow a minimum of 15 business days for shipping and process. Please note- quantities may be limited and requests are not guaranteed. Product substitutions may apply. Your request will be reviewed within 2 business days from submission. Fulfillment will be at the discretion of the American Medical Association.
Should be Empty:

Fulfillment Request Form

www.ama-assn.org/msop-resource-center