Application for Membership in the San Mateo County Medical Association and California Medical Association

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    Please complete this form and return to SMCMA
   777 Mariners Island Blvd  # 100 ,  San Mateo, CA 94404

    Name: __________________________________________________________

 

  Male Female

   Office address:

    Street: _________________________

  City: ____________________

 State________    Zip Code: ______
    Office phone: ____________________   Fax: _____________________

   Home address:
    Street: _________________________ City: ____________________ State_______     Zip Code:_____
    Date of birth: ___________________ Spouse (if applicable) ____________ Phone:_______________________

   Specialty/Practice *attach copy of certificate:  

   Specilaty #1: ________________________                                                 Board certified *    yes       no

   Specilaty #2: ________________________                                                 Board certified *    yes       no
 

   Training:

   Medical school: ____________________________________________ Year of grad: ______________
    Internship: __________________________ Specialty: ________________ From: _________ To: ___________
    Residency: __________________________ Specialty: ________________ From: _________ To: ___________
    Residency: __________________________ Specialty: ________________ From: _________ To: ___________
    CA Medical License Number:_____________ 
    Language(s) spoken other than English: _________________________________

                                                        _____________________________

__________________________________________________________________________________________

      Payment types accepted: VISA, MC, Discover or Check payable to the "San Mateo County Medical

      Association". Please mail checks to the address listed above.

 

      Note: Application will not be processed until dues payment is received.

 

     Credit Card # (VISA/ MC/Discover): ______________________       Exp. (month/year): ______________________

________________________________________________________________________________________________________

       Signature: ___________________________                                 Date: ___________________