Active Online Membership Application | NC Society of Gastroenterology

Active Membership Application for MD’s and DO’s

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

We will also need a copy of your current curriculum vitae or and updated resume. And a reference list (see below). You may email those directly to sbuchanan@meckmed.org.

Active Membership for MD’s and DO’s: 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*

Middle Name/Initial

Last Name*

Suffix (Jr., Sr., etc.)

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

Preferred E-mail:

Home Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Phone:

Area Code

-

Phone Number

Mobile Phone:

Area Code

-

Phone Number

Organization:

Office Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

Office Phone:

Area Code

-

Phone Number

Office Fax:

Area Code

-

Phone Number

Preferred Mailing Address

Home

Office

Education Information

Medical/Graduate School

Degree

Grad Date:

Residency

Subject

Res Start Date

Res End Date

GI Fellowship

GI Start Date

GI End Date

Actively Practicing Gastroenterology Since

Board Certification

Internal Medicine

No

Yes

IM Date

Gastroenterology

No

Yes

Gas Date

References

List the names of two actively practicing physicians, in any field, who can vouch for the candidates 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

First

Last

Reference 1 Phone

Area Code

-

Phone Number

Reference 1 E-mail

Reference 2 Name

First

Last

Reference 2 Phone

Area Code

-

Phone Number

Reference 2 E-mail

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

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

Authorization*

YES

Membership Option*

Word Verification: