MEMBERSHIP APPLICATION
DELAWARE STATE OSTEOPATHIC
MEDICAL SOCIETY
Current annual dues (please check one classification):
1 st Year of Practice $75
2nd Year of Practice $200
3rdYear 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: ________
Degree: ___________________________
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: _______________
Please return completed application with payment to:
Delaware State Osteopathic Medical Society
4142 Stanton-Ogletown Road #127
Wilmington, DE 19713.
Our phone is: (228) 547-3412