mobile-membership-app

GGSM MEMBERSHIP APPLICATION

All fields are required unless otherwise indicated.

PHYSICIAN INFORMATION

Full Name

Designation

DO MD PA

Gender Identification

Male Female Other

Other Gender

Spouse's Name

Date of Birth

Place of Birth

Preferred Email Address

Personal Phone Number

Home Street Address

CURRENT PRACTICE INFORMATION

Practice Name

Full Practice Address

Practice Phone Number

Practice Fax Number

Date Started at Current Practice

Specialty

TRAINING & SPECIALTIES

Medical Education

(current name of school)

Date of Degree

(for MD/DO/PA degree)

Post Graduate Training

Dates of Training

Board Certified?

Yes No

In What Specialty?

Year of Last Training

LICENSING & PRIVILEGES

For medical license(s), please list the state in which the license was issued, and the date it was issued.

Initial License

Other License(s)

NC License Number

Date Issued

Method

By Examination By Reciprocity

Hospitals Where You Have Current Privileges

MEMBERSHIP SPONSORS

Please list the GGSM member physicians who are sponsoring your application

Sponsor 1

Sponsor 2

Sponsor 3

SIGNATURE

If elected to membership, I agree without reservation to conduct myself professionally and personally according to the principles and medical ethics of the American Medical Association and to be governed by the Constitution and Bylaws of the Greater Greensboro Society of Medicine & the North Carolina Medical Society.

Agree to Pledge?

Yes

I certify that by typing my name in the signature field I am electronically signing this application.

Certify Signature?

Yes

Signature