Clark County Medical Society Alliance Membership Application
Clark County Medical Society Alliance Membership Application
Please complete the following form and submit.
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All physicians’ spouses are welcome in the Clark County Medical Society Alliance.
Join now to belong to an organization representing the family of medicine today.
The information provided is private and for the convenience of members only.
Member Name
Member Name
*
First
Last
Address
Address
Street Address
Address Line 2
City
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State / Province / Region
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Phone
Phone
-
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-
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####
Fax
Fax
-
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-
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Work Phone
Work Phone
-
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-
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Cell Phone
Cell Phone
*
-
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-
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####
Email
*
Occupation / Educational Background:
I am a Physician:
*
I am a Physician:
No
Yes
Please check one:
(Myself):
*
Please check one:
(Myself):
MD
DO
My Specialty:
*
My Spouse is a Physician
*
My Spouse is a Physician
No
Yes
Spouse’s Name
Spouse’s Name
*
First
Last
Spouse’s Specialty:
*
Spouse’s Practice/Group Name:
Spouse’s Practice/Group Phone Number:
Spouse’s Practice/Group Phone Number:
-
###
-
###
####
Please check one:
(Spouse):
*
Please check one:
(Spouse):
MD
DO
Type of Membership:
*
Type of Membership:
Regular $125
Associate Member: Resident/Widow/Retired/Military $30.00
I have an interest in the following special interest groups:
Choose ALL that apply
I have an interest in the following special interest groups:
Choose ALL that apply
Book Club
Toddler Play Group
Cooking Club
Dining Group
Fitness/Nutrition
None at this time
(Other Suggestion)
(Other Suggestion)
Are you interested in leading/starting a Special Interest Group?
Are you interested in leading/starting a Special Interest Group?
Yes
No
What type of a Special Interest Group are you interested in leading/starting?
I would like information on the following committees:
Choose ALL that apply
I would like information on the following committees:
Choose ALL that apply
Legislative
Fashion Show
Community Health/Outreach
Holiday Scholarship Project
Medical Office Practice Managers
American Medical Association Alliance (AMAA) Western Regional Conference Planning Committee (Conference in Jan. 2018)
Opiate Epidemic-Health Initiative
None at this time
(Other Suggestion)
(Other Suggestion)
Today's Date
Today's Date
*
/
MM
/
DD
YYYY
Unless you otherwise direct in writing, the information provided herein, will be placed in the Membership Directory, provided to Members ONLY. I agree that CCMSA may use photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
I have read and understand the above:
Draw your signature into the box below.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.
After submitting this form, you will be redirected to the payment page to enter your payment info.
$
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Total