Membership can become the initial step of a rewarding overall experience. We encourage you to join our association of black doctors to help foster growth and development in your chosen profession. Today's Date* MM slash DD slash YYYY Name* First Last Username* Upload Your Profile PhotoAccepted file types: jpg, gif, png, Max. file size: 1 MB.Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth MM slash DD slash YYYY Home Phone*Work Phone*Email* Medical Specialty* Texas Medical License/Permit Number* EducationCollege* 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 CertificationPrimary Specialty Date MM slash DD slash YYYY Subspecialty Date 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