Application for Medical Society Membership Form

DIRECTIONS: Please complete all parts of this application. Payment for the appropriate amount of dues online or by check must accompany your application; consult the membership categories page of our website to calculate dues and for the link for payment. Please also submit with your member application a current headshot for the PCMS directory and website. Membership in the Pueblo County Medical Society does not require membership in the Colorado Medical Society, but is strongly suggested.

I wish to join:

Colorado Medical Society: Dues $ (State medical society recommended)

Pueblo County Medical Society: Dues $ (Local medical society required)

Last Name:

First Name:

M.I.:

Degree:

Birthdate:

Gender:

Male Female

Primary Office:

Name:

Phone #:

Fax:

Address:

Street:

Suite:

City:

State:

Zip:

Email:

Website:

Personal Information:

Your personal information will not be shared with anyone.

Spouse Name:

Please choose one:

Mr. Ms. Mrs. Dr.

Address:

Street:

Suite:

City:

State:

Zip:

Phone:

Email:

Preferred Mailing Address:

Office Home

Preferred Email Address:

Office Home

Specialty:

Board Certification:

Medical School:

Full name of Institution:

Type of Training/Specialty:

Began Mo / Yr - Graduated Mo / Yr:

Residency:

Full name of Institution:

Type of Training/Specialty:

Began Mo / Yr - Graduated Mo / Yr:

Fellowship/Preceptorship:

Full name of Institution:

Type of Training/Specialty:

Began Mo / Yr - Graduated Mo / Yr:

Other Graduate Degrees:

Full name of Institution:

Type of Training/Specialty:

Began Mo / Yr - Graduated Mo / Yr:

Are any of the following conditions currently in process or have they occurred since your last application, either on a voluntary or involuntary basis: denied, revoked, suspended, reduced, limited, placed on probation, not renewed or relinquished for disciplinary reasons?

Membership on any hospital / medical staff?

Yes No

Medical license in any state?

Yes No

Professional society membership?

Yes No

Are there any judicial or regulatory actions pending which could result in denial, restrictions, suspension, or revocation of your license to practice medicine?

Yes No

(All "Yes" answers to the following require full explanation)

If elected to membership, I agree to conduct myself professionally and personally according to the AMA Principles of Medical Ethics and to be governed and bound by the Constitution and Bylaws of the society(ies) for which I am applying.

I hereby release, and hold harmless from any liability or loss, the society(ies) for which I am applying, their officers, agents, employees, and members, for acts performed in good faith and without malice in connection with evaluating my application, credentials and qualifications. I hereby release any and all individuals, organizations, and agencies or their authorized representatives from any liability concerning information provided about my professional competence, ethical conduct, character, and other qualifications for membership.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Applicant's Signature:

Date:

Please email application to contactus@pueblocountyms.org or postal mail to: 1925 E. Orman Ave., Ste. A448, Pueblo, CO 81004

Once your application is approved, you will receive a dues receipt via your preferred email address. Please attach your professional photo for use in our pictorial directory and Website.

For Office Use:

The Board of Directors of the Society having fully considered this application and appropriate supporting documents recommends the following actions:

Accept Reject

Signature:

Date:

Your information will be encrypted.