Complete this form and submit by faxto 704-376-3173, or mail to MCMS, 1112 Harding Place, Suite 100, Charlotte, NC28204, or scan and email to email@example.com. List only specialtiesrecognized by the American Board of Medical Specialists or AOA.
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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.
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Reviewed by_________________________________________________ Date ________________
Mecklenburg County Medical Society Secretary
Date Approved by the MCMS Board of Directors____________ ______________________________
MCMS Executive Director