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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.

Personal Information

First Name *

Last Name *

Middle Name *

Suffix

Degree (MD, DO, PA) *

Gender *

MaleFemale

Date of Birth *

Spouse/Partner's Name

Home Address *

Apartment, suite, etc.

City *

State/Province *

ZIP / Postal Code *

Primary Phone *

Email *

Practice/Group Information

Practice Name *

Primary Specialty *

Secondary Specialty

Practice Address *

Suite

City *

State/Province *

ZIP / Postal Code *

Practice Phone *

Practice Email

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 = $300MD/DO PT or Early Retired = $150PA = $105

Application Date *

By submitting an application for membership you are agreeing without reservation to conduct yourself 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

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