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Application for Membership

1st year $270*

Please complete the following membership application. Once the form is complete, click submit. MSDC will then contact you to confirm your membership and secure payment information.

Fields with the * symbol are required.

biographical data

*First Name:

Middle Initial:

*Last Name:

*Primary Office Address 1:

Primary Office Address 2:

*Primary Office City:

*Primary Office State:

*Primary Office Zip:

Group Practice Name/
Associates (if applicable):

*Primary Office Phone:

Phone numbers should be in
555-555-5555 format.

*Primary Office Fax:

*Email Address:

Specialty:

Hospital Privileges:

*Home Address 1:

Home Address 2:

*Home City:

*Home State:

*Home Zip:

*Home Phone:

Phone numbers should be in
555-555-5555 format.

Home Fax:

*Prefer Mail By:

	1st class
	Fax
	Email

*Preferred Mailing Address:

	Office
	Home

*Preferred Billing Address:

	Office
	Home

*Date of Birth:

*Gender:

	Female
	Male

Foreign Language (s) spoken (including sign language):

I am an AMA member:

	Yes
	No

I want to join the AMA:

	Yes
	No

Please list the activities, projects, or issues in which you feel the Medical Society should be involved or can assist you in your practice:

obligation for membership

I certify that to the best of my knowledge, the information that I have provided in this application is true and accurate. If elected to membership, I hereby agree to be governed by the Constitution and Bylaws of the Medical Society of the District of Columbia, and to abide by the regulations prescribed therein. Also, I hereby authorize the release of any information concerning my character, reputation, ability, medical practice or conduct by any medical society, hospital, licensing authority, medical school, peer review committee, or individual to the Medical Society of the District of Columbia and agree to hold harmless any person or organization making such release, as long as such release is made in good faith and without malice.

I understand that by providing my mailing address, email address, telephone number and fax number I consent to receive communications sent by or on behalf of MSDC (and its subsidiaries and affiliates) via regular mail, email, telephone, or fax. I understand that MSDC may share my address/email/telephone/fax with other organizations.

*I agree to the terms of the Obligation For Membership: