Solano County Medical Society

Solano County Medical Society / California Medical Association

MEMBERSHIP APPLICATION

Name *

as shown on CA MD/DO License

first

middle

last

CA MD/DO License Number *

Date of Birth

Work Address *

use this address for SCMS/CMA correspondence and publications

Street

City

State

ZIP

Office Telephone Number *

Area Code

Office Fax Number *

Area Code

Email Address *

Home Address

use this address for SCMS/CMA correspondence and publications

Street

City

State

ZIP

Home Telephone Number

Area Code

Spouse's Name

Specialty *

Board Certified?

Yes No

Subspecialty 1

Board Certified?

Yes No

Subspecialty 2

Board Certified?

Yes No

Medical School *

Year of Graduation

Internship *

Year of Completion

Residency *

Year of Completion

Previous California Medical Association (CMA) Active member?

Yes No
I am interested in AMA membership.

Mode of Practice *

Membership Status

$915.00

Active (practicing in Mendocino-Lake County with a physician & surgeon certificate issued by the MBC or OMBC).

$458.00

Part time and 65+ years old (working 1-20 hours/week and are 65+ years old).

$458.00

Government (receive more than 50 percent of their practice income from county, state or federal employment).

$50.00

Retired (have a retired license or license fee waiver from the MBC or OMBC).

$250.00

Multiple. (active member of another CMA component medical society)

Payment Details

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The foregoing is true and complete, and I endorse the Principles of Medical Ethics of SCMS, CMA and AMA.

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