Tuesday, December 12, 2017

Please select appropriate membership category. Return to Membership Category explanation.

Now Through 11/30/2017, take advantage of our special half price offer on first year membership and active previous member rejoin.

Please complete items applicable to your membership category.

All Membership Categories

First Name Middle Last Name MD/DO/Other

Date of Birth Medical School Graduation Date

Home Address

City State Zip Code

Home/Cell Phone Preferred Email Address

Active/Non-Resident/Associate/Health Care Administrator Members, please complete the following:

Practice/Group Name Web Address

Primary Office Address

City State Zip Code

Primary Office Telephone Office Fax

Primary Specialty Board Certification Secondary Specialty Board Certification

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Preferred Mailing/Billing Location:

If accepted as a member, I agree to abide by the Academy of Medicine of Cincinnati Articles of Incorporation and Code of Regulations. I understand and agree that by providing my address, email(s), telephone numbers(s), and fax number(s), I consent to receive communications sent by or on behalf of the Academy of Medicine of Cincinnati via regular mail, email, telephone, or fax.

By checking I agree to the terms and conditions above.


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