03/27/09
2009 MEDICAL STUDENT MEMBERSHIP APPLICATION Please Type or Print Your Name Exactly As It Will Appear on Your Medical License: First Name: Middle Name: Last Name: Local Home Address: City: State: ZIP Code: Telephone: Fax: Email: Sex: Male
or Female
Date of Birth: Place of Birth: Medical School: University Of California San Diego Medical Degree: MD Prospective Date of Medical Degree: Applicant’s Signature*: Application Date: * By signing this application, the applicant certifies that he or she is in good standing in an accredited training program, that he or she has not been convicted of a felony, and that he or she endorses the principles of medical ethics of SDCMS, CMA, and AMA. Membership in SDCMS, CMA, and MSS shall not be denied or abridged on account of sex, color, creed, religion, ethnic origin, national origin, age, disability, or sexual orientation.
MEDICAL STUDENT MEMBERSHIP DUES = $0 This form is an application for combined membership in the San Diego County Medical Society (SDCMS) and the California Medical Association (CMA). As this application is for membership to both organizations, your information will be processed by SDCMS and forwarded to CMA. SDCMS-CMA dues are waived for medical students. This membership will continue until your expected graduation date. If you continue your education and do not go into residency by your expected graduation date, please let us know. If you change your address at any time during your years of medical school, please let us know. Thank you! FAX THIS APPLICATION TO SDCMS: (858) 569-1334 MAIL THIS APPLICATION TO SDCMS: 5575 Ruffin Road, Suite 250 San Diego, CA 92123 CONTACT SDCMS WITH QUESTIONS: (858) 565-8888 • SDCMS@SDCMS.org
PLEASE FILL OUT APPLICATION COMPLETELY OR JOIN ONLINE AT WWW.SDCMS.ORG