Membership Application

MEMBERSHIP APPLICATION
DELAWARE STATE OSTEOPATHIC
MEDICAL SOCIETY

Current annual dues (please check one classification):

1 st Year of Practice              $75
2^nd Year of Practice            $200
3^rdYear of Practice             $300
Retired/Intern/Resident         $ 0

PERSONAL (Please print or type all information)

      Name:      ____________________________________________      AOA Number:  _____________________________

Business Name and Address: ________________________________________________________________________

       Mailing Address: ___________________________________________________________________________________
       Office Telephone #: ___________________________________________ Office Fax #:  __________________________
 

E-MAIL ADDRESS (E-mails will be sent for all DSOMS correspondence): 
 

Please print clearly: _________________________________@_______________________________
 

Home Address: _____________________________________________________________________________
 

       Home Telephone #: _________________    Home Fax #: ____________________  Cell #: __________________

       Mailing Preference: Home _______ Office _______

       Date of Birth:   __________________________     Place of Birth: __________________________________

Marital Status: S   M   D   W               Spouse Name: _____________________ 

PRACTICE

         Resident: ___________________   Intern: ___________________ Student: __________________

       Date started practice: _________________
 

Type of practice: Solo ___  Group ___ Partnership ___ Institutional ___ Other _____________

Specialty: ___________________________________________________________________

       Subspecialty: ________________________________________________________________
 

        Fellowship: _________________________________________________________________
 

Board Certified: Yes ______  No: ______   Board Eligible: ___________  Date: ____________

Specialty College(s): __________________________________________________________

       Delaware License #:  ___________________________    Date Licensed: _____________________

       Other State License(s): _________________________________________________________

             Hospital Affiliation(s): __________________________________________________________

                                                                                               Name of Hospital

EDUCATION

      Pre-Osteopathic College: ________________________________Year Graduated: ________

      Internship: __________________________________________________________________

                                                      (Institution Name)                                     City/State                                                               Year

   Residency: ___________________________________________________________________

                                                                (Institution Name)                            City/State                                       Year

   Residency: _________________________________________________________________

                                                                (Institution Name)                            City/State                                       Year

OTHER

      Additional Post-Graduate Training: ________________________________________________

      List membership in other associates: _______________________________________________ 

      Honors/professional accomplishments: _____________________________________________

      Teaching or faculty positions: _____________________________________________________

      Other comments: ______________________________________________________________

                                             ___________________________________________________________________________

I have indicated the form of payment for my membership dues, with the understanding that the
funds will be returned to me should the DSOMS Board of Trustees not approve my application.

Attached is a check made out to "DSOMS" in the amount of $ _________

I hereby agree to practice, comply and govern my conduct in accordance with the Code of Ethics of the Delaware State Osteopathic Medical Society and such standards of conduct and practice
ethics adopted by the association. I certify that the answers herein are complete and true to the
best of my knowledge. I hereby authorize the release of information to DSOMS for the purpose
of investigation of my professional credentials and personal character as needed to process my
membership application.

   Signature: _________________________________     Date: _______________