Membership Appl;ication - Richmond County Medical Society of Staten Island

Membership Dues

Active Membership	$739.00
Young Physician (under age 40 or within 5 years of residency completion)	$210.00
One-time Application Fee	$ 15.00
Corresponding Membership	None

RICHMOND COUNTY MEDICAL SOCIETY
460 Brielle Avenue
Administration Building,
Room 202
Staten Island, NY 10314

(718) 442-7267
Fax: (718) 273-5306
rcmsasst@aol.com

RICHMOND COUNTY MEDICAL SOCIETY
Membership Application

[FrontPage Save Results Component]

Physician/ Information
First Name: Last Name:
Date of Birth (mm/dd/yyyy) Month: Day: Year:
Nationality:
Marital Status: Spouse's Name: Single Married Widowed
Medical Degree: Year of Graduation:
University's Name:
University's Country:
Specialty:
State of License: License Number:
State of License: License Number:
Board Certified: Yes No	If you are Board Certified, what is your specialty?
Home Address:
Home Address :
City: State: Zip Code:
Home Telephone: Fax Number:
E-Mail Address:

Office Information
Office Address:
Office Address:
City: State: Zip Code:
Office Telephone: Office Fax Number:
Send Correspondence to: Office Home
Have you been a member of the Society in the Past? Yes No Year:
PHYSICIAN'S ATTESTATION: In applying form membership, I agree to comply with the bylaws, rules and regulations of the county society, the district branch, and the Medical Society of the State of New York. In providing fax and e-mail information, I give the medical societies permission to send me news update, important legal/legislative notices, seminar invitations, advertisements and web links." Members sponsoring this application: Member: Member:
Please note that the County Society may require additional information.