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Membership Application

New York County Medical Society
Medical Society of the State of New York
Membership Enrollment Form 2015 Dues Application

Take advantage of all the membership services available, and benefit from the Society’s proactive health policy and legislative activities. Just fill out this membership enrollment form. Dues are listed below. Payment information will appear following submission of this form.

2015 Dues Payment Information
Your dues payment covers your membership costs from your date of election as a member through December 31, 2015

Membership Category NYCMS Dues MSSNY Dues MSSNY Fee++ Total NYCMS/ MSSNY
Full Active $390 + $460 + $35 = $885
Part Time* $195 + $230 + $10 = $435
Young Physicians** $100 + $100 + None = $200
Interns, Residents, and Fellows $20 + $25 + None = $45

++This represents a one-time fee.
* Defined as working 20 hours or less a week
** Under age of 40 or less than five years in practice. One year offer only. Second and third young physician years at 50% and then 75% of full active dues.

You may also apply to the American Medical Association with this application simply by including the correct dues amount and checking the box below. Although it is optional, we urge you to extend your membership to the national arm of your federation of organized medicine, the AMA.

AMA Dues: Full Active: $420; 1st Year in Practice: $210 2nd Year in Practice: $315; Resident/Fellow: $45

Check here if also applying to the American Medical Association (AMA).

Name

Gender Male Female

Date of Birth

Mail to Home Office

Office Address
Home Address
City
City
State
ZIP
State
ZIP
Phone
Phone

Fax

E-mail

Medical School
Year of Graduation MD DO

Chronological list of training, military service, and practice experience since medical school. Include current hospital affiliation(s). (If you are a resident, give program and PG year.) One entry per line, please.

Dates Hospital/Location Position/Specialty

Specialty
Second Specialty or Subspecialty
Third Specialty or Subspecialty
Fourth Specialty or Subspecialty

Board Certified Which Board?

Date Entered Practice

Group Name (If applicable)
Does Group Pay Your Dues? Yes No

Employer Name (If applicable)
Does Employer Pay Your Dues? Yes No

By submitting this form, you, as a new member, agree to abide by the Principles of Medical Ethics and the Bylaws of the associations.


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