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Membership Application


Red Outlined Fields Are Required

Applicant Type:    
Personal Information
Gender *
Advanced Degree/Licenses *
MD, PA, DO and other advanced degrees. Will display in order entered.
Name *    
Spouse/Partner's Name  
Home Address
Home Address - Line 2
City, State Zip ,  
Home Phone
Ex. (509) 555-4567
Home Fax
Ex. (509) 555-4567
Cell
Ex. (509) 555-4567
Preferred Email
Used as SCMS contact. Not displayed on website. Preferred contact for emails from SCMS.
*
Preferred Method of Communication
Date of Birth
Enter as (mm/dd/yyyy)
*
Place of Birth
US Citizen
Interests/Hobbies/Civic Organizations/Research/Family
Enable Secondary Group/Practice Location
Practice Information
Practice/Group Name *
Start Date at Practice *
Practice Type
NPI #
Languages Spoken
Available Languages
Current Languages

Medical Education / Training
Medical/Physician Assistant School
Medical/Physician Assistant School Address
Graduation Year
Type Institution Location Degree/Specialty Dates
  X

Previous Practices (In chronological order starting with most recent)
Practice Name Address City, State Dates
,   X

Board Certifications
SpecialtyPrimary PracticeBoard CertifiedCertified ByExpiration Date
Membership Application and Qualification Questions / Information Release
Previous Medical Society Membership

Member will abide by SCMS bylaws and the WSMA Principles of Medical Ethics. Please provide answers to the following questions, sign and date.

If you answer yes to any of these questions, please attach full information.

Have you ever been convicted of fraud or a felony? *
Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine? This includes actions involving revocation, suspension, limitation, probation, or any other imposed sanctions or conditions. *
Have you ever been the subject of any disciplinary action by any medical society or hospital medical staff? *

I hereby apply for membership in the Spokane County Medical Society and agree to abide by its Bylaws and the WSMA Principles of Medical Ethics. In consideration of the Spokane County Medical Society processing my application for membership, I grant permission and consent for their obtaining verification of information provided on this application.

I hereby release, and hold harmless from any liability or loss, the Spokane County Medical Society, its officers, agents, employees and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications who, in good faith and without malice, provide information to the Spokane County Medical Society or to its authorized representatives concerning my professional competence, ethical conduct, character and other qualifications for membership.

Initials and Date *      
Optional Contact Info
Private Data Only Displayed to SCMS Members
Personal Info
Backline Office Phone
Only Displayed to SCMS Members
Personal Email
Only Displayed to SCMS Members
Personal Cell
Only Displayed to SCMS Members
Home Phone
Only Displayed to SCMS Members
Home Address
Only Displayed to SCMS Members
Notes for Colleagues
Only Displayed to SCMS Members

Spokane County Medical Society
Ph: 509.325.5010 | Fax: 509.325.5409
901 E. 2nd Avenue, Suite 301 | Spokane, WA 99202