Application for Resident Membership

Ohio Dermatological Association

Any resident physician currently in good standing in dermatology and/or related subspecialty training program in Ohio is eligible for Physician in Training (Resident) membership

Name *

First

Middle

Last

DO/MD

Residency Information

Dermatology Residency Training

Institution

Institution Address

Address Line 1

Address Line 2

City

State

Zip Code

Institution Phone

Institution Fax

Dates of Residency Training

Home Information

Email *

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Date of Birth *

Education Information

Medical School

Degree

Year

Year Licensed in Ohio

Ohio Medical License Number

Are there any current or pending restrictions on any medical license?

License suspensions?

If an ODA Mentor has been assigned to you, please list his/her name.

PLEASE READ CAREFULLY AND COMPLETE THE FOLLOWING

I hereby release from liability all representatives of the Ohio Dermatological Association for their acts performed in good faith, without malice and in reasonable belief that any information gathered or exchanged is warranted by the facts known to them.

I understand and agree that this release and consent is irrevocable. I understand and agree that I, as an applicant for membership, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications for membership.

Date

Residency Certificate

Click or drag a file to this area to upload.

Annual Membership Fee

Price: $0.00