Membership Profile Application Page 1 Page 2 Page 3 Web Site General Information (pg 1 of 3) Today's Date * Membership Type (annual fees) Active Member First Year ($150) Active Member ($295) Limited Practice: <20 hrs/wk ($150) Retired ($150) Resident/Medical Student (n/c) Physican Assistant ($150) Credential Choose One MD DO PA Last Name * First Name * Contact Number * Alternate Contact Number Email Address * Office Mailing Address Home Mailing Address Office City Home City Office Zip Home Zip Education Summary (pg 2 of 3) Medical School or Physicians Asst School Residency Hospital Graduate Training / Fellowship Graduation Date Residency Dates Grad Dates Practice (pg 3 of 3) Type of Practice (Specialty) Board Certified? Yes No Date of License License Number Has your license ever been limited, suspended, or revoked? Yes No Have you ever been licensed in another state? Yes No If yes, which state? - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Are you interested in serving on the Board of Director? Yes No Are you interested in serving on the CME Committee? Yes No