Return to home page

MCMS Membership Application

STEP 1 - I am Applying for a Membership
Doctor of Medicine or Doctor of Osteopathic Medicine
- First Year
Second Year or Above
Active in medical training within Maricopa County
- I DO want a subscription to Round-up Magazine
- I DO NOT want a subscription to Round-up Magazine
Contact MCMS if you do not fit within the above categories.
STEP 2 - Method of Payment
$0
STEP 3 - Tell Us a Little About You
*
 
  *
*
M    F

   

*
*
  *
  *
*
 
*
This will be your username for the members only area of the MCMS Web site.
*
This will be your password for the MCMS Web site. It will also be used as your Signature code below.
*
*
 



Yes    No
 
    
Example: 10/23/2004
STEP 4 - Mailing Address
For MCMS Official Business and Communications
Same as above.
*
*
*
  *
  *
*
 
STEP 5 - Statement of Understanding
I authorize all individuals, institutions, and entities (past, present, and future) including all professional liability insurers, who have knowledge concerning my qualifications and other information requested in this application to consult with and release relevant information and records to MCMS.*

I further agree, as evidenced by this signed application for membership, to furnish the Society with all information relative to any claim or action filed against me for malpractice, and I authorize and consent for the Society to obtain from my present and/or past liability insurance carrier any and all information regarding insurance coverage, premiums, claims and suits against me as well as settlements made on my behalf.*

I verify that all the information entered into this form is true and accurate to the best of my knowledge and that submission of this form enters me for consideration as a member of the Maricopa County Medical Society. MCMS membership will be effective upon vetting of this application and additional information provided by me to finalize the application process.*

  Fields marked with * are required.