Physician Membership Application - Mecklenburg Medical Society

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 ssmith@meckmed.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.

You will be taken to PayPal to complete your purchase with your credit card.

Personal Information

Full Name:*

Suffix:

Degree (MD, OD, PA, etc.):

Gender:

DOB:

Spouse/Life Partner’s Name:

Mailing Information

Practice/Group Name:

Date Began:

Primary Specialty:

Secondary Specialty:

Practice Address:

Practice City:

Practice State:

Practice Zip:

Office Phone:

Office Fax:

Office Email:*

Office Website:

Home Address:

Home City:

Home State:

Home Zip:

Home Phone:

Home Fax:

Education

Medical School:

Date of Graduation:

Internship (Institution/Year):

Year Completed (I):

Residency (Institution/Year):

Year Completed (R):

Residency/Fellowship (Institution/Year):

Year Completed (F):

Board Certifications

Certified by the American Board of (1):

Year (1):

Certified by the American Board of (2):

Year (2):

Select a Membership Category:*

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.

Your full name in lieu of your signature:*

Date:

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Click on the Submit button to send your registration to MCMS.

You will be taken to PayPal to complete your purchase with your credit card.

For Office Use Only:

Reviewed by_________________________________________________ Date ________________

Mecklenburg County Medical Society Secretary

Date Approved by the MCMS Board of Directors____________ ______________________________

MCMS Executive Director

Physician Online Membership Application