Application for Active Membership | Ohio Dermatological Association

Name *

First

Middle

Last

Date of Birth *

Office Information

Company Name *

Office Address *

Address Line 1

Address Line 2

City

State

Zip Code

Office Phone *

Office Fax *

Office Website / URL *

County *

Practice Associates *

Home Information

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone

Email *

Preferred Mailing Address *

Office
Residence

Education Information

Medical School *

Degree *

Year *

Year Licensed in Ohio *

Ohio Medical License Number *

Licenses in Other States *

Residency *

Institution

*

Dates

*

Type

Dermatology Residency Training *

Institution

*

Dates

Fellowship *

Institution

Dates

*

Speciality

Additional Information

Board Certified in Dermatology?

Board Certified in Dermatology? *

Yes
No
Pending

American Board of Dermatology
Osteopathic

Year

Member, American Academy of Dermatology

Member, American Academy of Dermatology? *

Yes
No

Classification

Year

Member, American Osteopathic College of Dermatology

Member, American Osteopathic College of Dermatology? *

Yes
No

Classification

Year

Medical Education Number *

Society Memberships (List) *

University Appointment *

Local Hospital Staff Memberships *

Former Hospital Staff Memberships *

Former Place(s) of Practice With Dates *

Formerly a member of a county medical society?

Formerly a member of a county medical society? *

Yes
No

City

State

Have you previously been a member of the ODA?

Formerly ODA member? *

Yes
No

Year

Reason for not maintaining membership:

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

License suspensions? *

Yes
No

Explanation

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.

I agree to return my certificate of membership if my license to practice medicine “in any state” is revoked, suspended, or limited beyond its present state, or if my membership is revoked for such other causes as may be placed legally in the bylaws of the Association.

I acknowledge responsibility for my membership dues.

Signature *

Clear Signature

Membership Fee *

Price: $275.00

Ohio Dermatological Association
698 Dalton Fox Lake Road
Dalton, Ohio 44618
Phone: 330.465.8281 Fax: 330.985.0036