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Pinellas County Medical Association

Become a Member

Application Type:

First Name:

Last Name:

Middle Initial:

Physician type

AMA Education Number:

Medical License Number:

Gender:

Date of Birth:

Spouse’s First Name:

Practice/Group Name:

Practice Website:

Practice/Group Administrator’s Full Name:

Practice Type

Primary Speciality:

Secondary Specialty:

Name of Member that referred you:

Contact Information

Please provide both sets of addresses.

You prefer to received email/mail at:

Office Email:

Office Phone with Area Code (xxx) xxx-xxxx format:

Office Address:

Office City:

Office State:

Office Zip:

Office Fax:

Please provide your home conact info as well.

Home Email:

Home Phone with Area Code (xxx) xxx-xxxx format:

Home Address:

Office City:

Home State:

Home Fax:

Education

Medical School:

Graduation Date:

Fellowship:

Fellowship Date:

Name of Board:

Certified In:

Certified Date:

Name of Second Board:

Secondary Certification:

Secondary Certification Date:

Primary Hospital:

Primary Hospital City:

Secondary Hospital:

Secondary Hospital City:

Membership Qualification Questions

Members abide by the AMA Principles of Medical Ethics and the bylaws of the Associations. To assist us in upholding these standards, please provide answers to the following questions, sign and date. If you answer yes to any of these questions, please attach full information.:

Fraud/Felony

Have you ever been convicted of fraud or a felony?

License Question

Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine? This includes actions involving revocation, suspension, limitation, probation, or any other imposed sanctions or conditions.:

Discipline Question

Have you ever been the subject of any disciplinary action by any medical society or hospital medical staff?

Acknowledgement

Please type your name: I am aware that the information submitted in this application will be verified. I hereby authorize other organizations having information relating to this applications, including governmental and regulatory entities, to release any and all such information. I understand that any false or misleading statement made on my application may be grounds for denial of membership or probably or censure by, or suspension or expulsion from the medical association. The foregoing information is true and complete.

Disclaimer: The information on this web site is general information, and not designed to be and should not be relied on as your sole source of information when analyzing.