Page 38 - OCMS3Q21

MSMS
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120 W. Saginaw Street· East Lansing, Ml 48823 msms@msms.org· www.msms.org 517-336-5762· Fax: 517-336-5797
MICHIGAN STATE MEDICAL SOCIETY
30700 Telegraph Road, Suite 3445 Bingham Farms, MI 48025
(248) 792-7062
State & County Medical Society Membership Application
Member Status: □ 1 st Year of Practice Post-Residency □ 2nd Year of Practice Post-Residency □ 3rd year of Practice Post Residency D I have moved into Michigan, and this is my first year practicing in this state. D I work 20 hours or less per week.
D I am currently in active military duty D I am in full-active practice
□ Male D Female
.Last Name_: ________________MD or DO? .Maiden Name (if applicable_) ______________
First (legal) Name_:
Nickname or Preferred Form of Legal Name_:
Job Title:-------------------------------------------- - - - -
W Phone:__________W Fax_: __________.H Phone_: ________ H Fax_: _________ Cell:____________Email: -------------------------------------
_ _ _ _ _ _ _.Middle Name_: __________
Office Address: D Preferred Mail D Preferred Bill D Preferred Mail and Bill
_ _ _ _ _ _
City_:
__________________ _ _ _ _ _ _
_
State_:
_ _ _ _Zip_: ____________
_ _ _ _Zip: _____________
Home Address: D Preferred Mail D Preferred Bill D Preferred Mail and Bill City:_____________________________State_:
Please base my county medical society membership on the county of my (if addresses are in different counties): D Office Address D Home Address !!
Birth Date: _ _ _ _ _ _ Birth Country_: ___________MI Medical License_# _________.ME_# _ _ _ _ _ Medical School:____________________ _Graduation Year_: _ _ _ _ECFMG# (if applicable_) _ _ _ _
Residency Program:_________________________ _Program Completion Year:
Fellowship Program:_________________________ _Program Completion Year:_ _ _ _ _ _ _ HospitalAffiliation(s)_: ___________________________________________
Primary Specialty:_______________________________Board Certified D Yes D No Yea_r _ Secondary Specialty: ______________________________Board Certified D Yes D No Yea_r _ Marital Status: D Single D Married □ Divorced Spouse's First Name_: _ _ _ _ _ _ Spouse's Last Name_: _ _ _ _ _ _ _ _ Is your spouse a physician?: D Yes D No If yes, are they a member of MSMS?: D Yes D No
Within the last five years, have you been convicted of a felony crime?: D Yes D No If "yes", please provide full information: Within the last five years, has your license to practice medicine in any jurisdiction been limited, suspended or revoked?:
D Yes D No If "yes", please provide full information:
Within the last five years, have you been the subject of any disciplinary action by any medical society or hospital staff?:
D Yes D No If "yes", please provide full information:
_ _ _ _ _ _ _ _
I agree to support the County Medical Society Constitution and Bylaws, the Michigan State Medical Society Constitution and Bylaws, and the I Principles of Ethics of the American Medical Association as applied by the AMA and the MSMS Judicial Commission.
SIGNATURE_:
__________________ _ _ DATE_:
_ _ _ _ _ County Medical Society Use Only
Reviewed and Approved by
38 SEPTEMBER/OCTOBER 2021 | WWW.OCMS-MI.ORG
When completed, please mail to MSMS or Fax to (517) 336-5797. Thank you!