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Mendocino-Lake County Medical Society / California Medical Association

MEMBERSHIP APPLICATION



Name *
as shown on CA MD/DO License
first
middle
last
 
CA MD/DO License Number *
Date of Birth
Work Address *
use this address for MLCMS/CMA correspondence and publications
Street
City
State
ZIP
Office Telephone Number *
Area Code
 -
 
Office Fax Number *
Area Code
 -
 
Email Address *
Home Address
use this address for MLCMS/CMA correspondence and publications
Street
City
State
ZIP
Home Telephone Number
Area Code
 -
 
Spouse's Name
Specialty *
  Board Certified?
Yes     No
Subspecialty 1
  Board Certified?
Yes     No
Subspecialty 2
  Board Certified?
Yes     No
Medical School *
 
Year of Graduation
Internship *
 
Year of Completion
Residency *
 
Year of Completion
Previous California Medical Association (CMA) Active member? Yes     No
I am interested in AMA membership.
Mode of Practice *
Membership Status
$790.00 (pro-rated)
Active (practicing in Mendocino or Lake Counties with a physician & surgeon's certificate issued by the MBC or OMBC). Applications received January-June pay full dues; July-September, 50%; October-December, no charge.
$790.00 (pro-rated)
Transfer (for transfers from another medical society, application fee is waived). Applications received January-June pay full dues; July-September, 50%; October-December, no charge.
$395.50
Active, Half time and 65+Yrs (working 1- 20 hours/week and are 65+ years of age).
$487.50
Government (receive more than 50 percent of their practice income from county, state or federal employment).
$120.00
Multiple (physician who is an active member of another CMA component medical society).
$0
Resident physician. (MLCMS pays annual $35 CMA dues.)
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Payment Details Send in Payment
All applicants (excluding residents and transfers from another medical society) pay an application fee of $200.


The foregoing is true and complete, and I endorse the Principles of Medical Ethics of MLCMS, CMA and AMA.



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