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Contact Information
4438 Oak Bridge Dr., Ste B
Flint, Michigan 48532
(810) 733-6260 - Phone
(810) 230-3737 - Fax
     

Medical Society Membership Application

Online Application

Please use the form below to apply for membership in the Genesee County Medical Society, component of the Michigan State Medical Society.  By applying for membership, you agree to support its Constitution and Bylaws, the MSMS Constitution and Bylaws, and the Principles of Ethics of the American Medical Association as applied by the AMA and the MSMS Judical Commission. All fields require a response.

First Name:
Middle Initial:
Last Name:
MD or DO:
MD DO
Practice Name:
Office Telephone:
Office Fax:
Office Email:
Office Address:
Office City:
Office State:
Office Zip Code:
Home Address :
Home City:
Home Zip Code:
Home Telephone:
I would like my GCMS/MSMS mail delivered to my:
Office Address Home Address

Date of Birth :
Place of Birth :
Male or Female: Male Female
Marital Status: Married Single
Spouse`s Name:
Hospital Affiliation(s):

Education
College/University:
Year Graduated:
Degree:

Medical School:
State/Country:
Year Graduated:

Internship:
Hospital:
City:
Specialty:
To/From Date:

Residencies or Fellowships:
Hospital:
City:
Specialty:
To/From Dates:

Hospital:
City:
Specialty:
To/From Dates:

If a graduate of foreign medical school, please include your ECFMG#:
Year Licensed in Michigan:
Michigan License Number:
Licenses held in other state(s):
Have you ever been dropped, expelled or suspended from any local, state or national medical society? No Yes
If yes, provide details:

Specialty
Board Certified?: No Yes
Specialty - Primary:
Year Board Certified:
Board Eligible?: No Yes

Secondary Board Certified?: No Yes
Specialty - Secondary:
Year Board Certified:
Board Eligible?: No Yes

Previous Practice History
Previous Practice Location 1:
To/From Dates:
Previous Practice Location 2:
To/From Dates:

Military Service
To/From Dates:

Additional Information
Current medical and/or specialty society memberships:
Fellow, American College of:
Date:
Teaching Appointments:
Associates in Practice:
Languages Spoken:


Comments and Request:

 

 

Genesee County Medical Society
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