Membership Application
Today's Date
*
Date Format: MM slash DD slash YYYY
Name
*
First
Last
Username
*
Mailing Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Date of Birth
Date Format: MM slash DD slash YYYY
Home Phone
*
Work Phone
Email
*
Medical Specialty
*
Texas Medical License/Permit Number
*
Education
College
*
City, State
*
Degree/Major, Date
*
Medical School
*
City, State
*
Degree/Major, Date
*
Internship Program
*
City, State
*
Dates
*
Residency
*
City, State
*
Dates
*
Fellowship
*
City, State
*
Dates
*
Board Certification
Primary Specialty
Date
Date Format: MM slash DD slash YYYY
Subspecialty
Date
Date Format: MM slash DD slash YYYY
Mode of Practice (Academic/Group?Solo/Gov)
Signature
*
Please enter your initials to indicate your signature.
Dues payments must be submitted at the time of application submission.
- Practicing physician $250/calendar year
- First year of practice $100/calendar year
- Resident/Fellow $50/calendar year
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