Active Online Membership Application 2 – NC Society of Gastroenterology

Active Online Membership Application

Active Membership Application for MDs and DOs

The society is a 501(c)(3) organization. Dues can be either a charitable deduction or a business expense.

Active Membership for MDs and DOs: Must have authentic medical or osteopathic licensure; be in good standing in the community and of sound moral and ethical nature and free of any felony conviction; must have board certification or fulfill the criteria for eligibility for board certification in gastroenterology.

Personal Information

Prefix

First Name *

Last Name *

Middle Name/Initial

Suffix (Jr., III, etc.)

Degree(s) (e.g. MD, PharmD, MS, BS)

Preferred Email *

Home Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Phone

Mobile Phone

Organization/Practice

Organization Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Organization Phone

Organization Fax

Preferred Mailing AddressHomeOffice

Educational Information

Medical/Graduate School

Degree Obtained

Graduation Date

Residency

Subject

Residency Start Date

Residency End Date

GI Fellowship

Fellowship Start Date

Fellowship End Date

Actively Practicing Gastroenterology Since

Board Certification

Internal MedicineYesNo

IM Date

GastroenterologyYesNo

Gastro Date

References

List the names of two actively practicing physicians, in any field, who can vouch for the candidate's character, clinical and/or research skills, and his/her dedication to the field.

References may be contacted by phone or e-mail.

Reference #1 Name

Reference #1 Phone

Reference #1 Email

Reference #2 Name

Reference #2 Phone

Reference #2 Email

Please upload your resume. The file must be less than 2meg.

No file chosen

By checking the box just below, I authorize North Carolina Society of Gastroenterology to obtain information from sources provided in this application regarding my qualifications for membership. This information will be kept confidential by the society.

References may be contacted by phone or e-mail.

Authorization *Yes

Membership Options *1 Year = $1753 Years = $450

I would like a to make a tax-deductible donation to NCSG to help offset the cost of the fellows’ complimentary participation in the educational annual conference.

USD