Application for Membership

Biographical Information

First:

Mi:

Last:

Title:

Date of Birth:

Birth Place:

Sex:

Female
Male

Spouse's Name:

Contact Information

Preferred mailing address: Home Office

Office:		Office Phone: Office FAX:

Home:		Home Phone: Home FAX:

	E-mail:

PA License No:	Date of issue:

Practice Information

Practice Type: Solo Hospital Based
Group Teaching / Research Other

If "Other", please give details.
If "Group" please give name and address:

Specialty:

Present Hospital Appointments (List Dates):

Personal & Professional Conduct

Within the last 5 years, have you been convicted of a felony crime?

Yes No

If "Yes", pleases give complete details:

Within the last 5 years, has your license to practice medicine in any jurisdiction been limited, suspended or revoked?

Yes No

If "Yes", pleases give complete details:

Within the last 5 years, have you been the subject of any disciplinary action by any medical society or hospital staff?

Yes No

If "Yes", pleases give complete details:

Declaration

If elected to membership, I agree to conduct myself professionally and personally according to the principles of medical ethics and to be governed by the Constitution and Bylaws of the Allegheny County Medical Society, the Pennsylvania Medical Society, and the American Medical Association.

Yes No

I hereby release, and hold harmless from any liability or loss, my County Medical Society, the Pennsylvania Medical Society, their officers, agents, employees, and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and hereby release from any liability any and all individuals and organizations, who, in good faith and without malice, provide information to the above named organizations, or to their authorized representatives, concerning my professional competence, ethical conduct, character and other qualifications for membership.

I also authorize the above named organizations, in the consideration of my application, to make inquiry of any of my references and institutions by whom I have been employed or extended privileges, as to my qualifications. I further authorize any of the above persons or institutions to forward any and all information their records may contain, and agree to hold them harmless for any action by me for their acts.

Yes No

By submitting this application, I certify that the information contained herein is true and correct to the best of my knowledge, and accept and agree that any information found to be false may be grounds for denial of membership or revocation of membership.