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New Member Application

Membership Application
Click the Submit button upon completing the below membership application to process membership payment with your credit card.

First Name *

Middle Initial

Last Name *

Suffix

Degree (MD, DO, PA) *

Gender

Date of Birth *

Spouse/Partner's Name

Home Address *

Apartment, suite, etc.

City *

State/Province *

ZIP / Postal Code *

Preferred Phone *

Preferred Email *

Practice/Group Information

Practice Name *

Practice Address *

Suite

City *

State/Province *

ZIP / Postal Code *

Primary Specialty *

Secondary Specialty

Education Information

Medical School *

Date of Graduation *

Internship

Year Completed

Residency

Year Completed

Fellowship

Year Completed

Board Certifications

Certified by the American Board of

Year

Certified by the American Board of

Year

Choose Membership

MD/DO - $300PA - $125Resident/Fellow - $50Emeritus/Retired MD/DO - $50

I would like to make a donation to support the Medical Society’s mission and programs to benefit the medical community.

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By submitting an application for membership you are agreeing 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. *

I Agree

In lieu of a written signature please check the box to proceed. *

I agree. This is in lieu of my signature.

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