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

Membership in the California Medical Association is a requirement for membership in the San Mateo County Medical Association. The American Medical Association is optional, but recommended.

Please complete this form and return to:
SMCMA777 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 __________________ 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: ___________________