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 firstname.lastname@example.org. List only specialtiesrecognized by the American Board of Medical Specialists or AOA.
Click on the Submit button at the bottom of this form to send your registration to MCMS.
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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.
Please type in your full name below - to act as your signature accepting the submission of this application.
Click on the Submit button to send your registration to MCMS.
For Office Use Only:
Reviewed by_________________________________________________ Date ________________
Mecklenburg County Medical Society Secretary
Date Approved by the MCMS Board of Directors____________ ______________________________
MCMS Executive Director