Wednesday, October 18, 2017
 
 

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








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

All Membership Categories

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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