Page 9 - Mecklenburg_Medicine_November-December-2017

Member News

1112 Harding Place, #200, Charlotte, NC 28204 • 704-376-3688 • FAX 704-376-3173 • meckmed@meckmed.org

Physician Membership Application

Complete this form and submit by fax to 704-376-3173, or mail to MCMS, 1112 Harding Place, Suite 200, Charlotte, NC 28204, or print and scan and
email to meckmed@meckmed.org. List only specialties recognized by the American Board of Medical Specialists or AOA. List your other qualifications
and certifications on a separate sheet. Send your headshot in jpeg format to meckmed@meckmed.org to be included in the monthly magazine.

MEMBERSHIP DUES: Active Membership $300 full year $300 Jan.-June; $150 July-Dec.
First Year Post-Residency $150 full year $150 Jan.-June; $75 July-Dec.

Full Name ________________________________________________________ Degree________________ DOB:________ /________ /________
Practice Name _____________________________________________________________________ Date Began:________ /________ /________
Practice Address __________________________________________________ City __________________________ Zip ____________________
Practice Phone ___________________________ Fax ______________________________
Email _____________________________________________ Secondary Email _____________________________________________
Home Address __________________________________________________ City __________________________ Zip ____________________
Primary Phone _______________________________
Spouse/Life Partner’s Name __________________________________________ Degree ____________________________________
Primary Specialty ________________________________________ Board Certified: Y N
Secondary Specialty ______________________________________ Board Certified: Y N
Medical School _____________________________________________________ Year Graduated_______________
Internship (Institution/Year) __________________________________________________________________________________
Residency (Institution/Year) ___________________________________________________________________________________
Residency/Fellowship (Institution/Year) _________________________________________________________________________
NC Medical Board License Number ___________________________________ Date Issued: ________ /________/_________
Second Language ___________________________________________________
Other Languages ________________________________________________________________________________________________________
Special medical interests or practice focus ____________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
If approved by the MCMS Board of Directors for membership, I agree without reservation to conduct myself professionally and personally according to the principles
of the medical ethics of the American Medical Association and to be governed by the Constitution and Bylaws of the Mecklenburg County Medical Society.

Signed ________________________________________________________________ Date: ________ /________/_________

For Office Use Only:
Reviewed by ___________________________________________________________ Date: ________ /________/_________

Mecklenburg County Medical Society Secretary

Date Approved by MCMS Board of Directors: _______ /________ /_ __________________________________________________________
MCMS Executive Director

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