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Membership Application & Qualifications Questions

Members abide by the AMA Principles of Medical Ethics and the by-laws of the Associations. To assist us in upholding these standards, 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 felony?
Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine? This includes actions involving revocations, 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 am aware that the information submitted in this application will be verified. I hereby authorize other organizations having information relating to this application, including governmental and regulatory entities, to release any and all such information.

I understand that any false or misleading statement made on my application may be grounds for denial of membership or probation or censure, or suspension or expulsion from the medical society. The foregoing information is true and complete.

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