Active Online Membership Application Active Membership Application for MD’s and DO’sThe 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 InformationPrefixSelect valueDr.Mr.Ms.Mrs.First Name*Middle Name/InitialLast 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 CodePhone: Area Code - Phone Number Mobile Phone: Area Code - Phone Number Organization: Office Address: Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeOffice Phone: Area Code - Phone Number Office Fax: Area Code - Phone Number Preferred Mailing AddressHomeOfficeEducation InformationMedical/Graduate SchoolDegreeGrad Date:ResidencySubjectRes Start DateRes End DateGI FellowshipGI Start DateGI End DateActively Practicing Gastroenterology SinceBoard CertificationInternal MedicineNoYesIM DateGastroenterologyNoYesGas DateReferencesList 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-mailReference 2 Name First Last Reference 2 Phone Area Code - Phone Number Reference 2 E-mailPlease 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*YESMembership Option*Select product1 Year = $1503 Years = $425SubmitReset