Application For Membership

*required fields

First Name:   *
Last Name:   *
Group Practice Name:  
Primary Office Address:   *
Phone:   *
City:   *
Zip:   *
Fax:  
Email:  
Additional Office Address:  
City:  
State:  
Zip:  
Phone:  
Date of Birth:  
Gender:  
Name of Spouse:  
Specialty:  
Ohio License Number:  
Date Issued:  
Specialty or special practice interests:  
Certification by Board of:  
Year:  
Hospital Affiliations:  
Medical School:  
City:  
State:  
Date Graduated:  
Internship (PGY1):  
Hospital:  
City:  
State:  
Dates:  
Training Specialty:  
Internship (PGY2,3,4):  
Hospital:  
City:  
State:  
Dates:  
Training Specialty:  
Post-Graduate/Fellowship:  
City:  
State:  
Dates:  
Training Specialty:  
Number of years in active practice:  
or Training Level:  
Professional Societies:  

Would you like to be placed on the AMC/NOMA's Physician Referral Line? Yes No
I would like to apply to be placed on the Academy's Physician referral Listing:  Yes No
Please provide the following information ( if "yes" to any of the questions below, please explain in the text box provided at the end of application)
1. Has your narcotic license ever been restricted in any manner? Yes
No
2. Has your license to practice in any jurisdiction ever been denied, restricted, limited, suspended, or revoked or have you ever been reprimanded by a licensing agency? Yes
No
3. Have your privileges or membership at any hospital or institution ever been denied, suspended, reduced, or not renewed, or have disciplinary proceedings ever been instituted against you? Yes
No
4. Have you ever been denied membership, or renewal thereof, or been subject to disciplinary proceedings in any medical organization? Yes
No
5. Is your physical or mental health such that it may impair your ability to practice medicine? Yes
No
6. Is your use of alcohol or chemicals such that it may impair your ability to practice medicine? Yes
No
7. Have you ever been convicted of a crime other than a motor vehicle citation? Yes
No
8. Do you have a felony or misdemeanor charge pending, other than a traffic violation? Yes
No

Please use this box to explain any "yes" questions from above

I hereby authorize persons or institutions in possession of information relevant to my application, or familiar with my reputation to:

(i) discuss with the AMC/NOMA or its employees or agents, my general reputation, standing in community and qualifications to be a

member of the AMC/NOMA; and

(ii) release or provide access to, or provide copies of information relevant to my application for membership.

I also authorize the AMC/NOMA to obtain information from any state, federal or other organization that collects information relevant to my application. Furthermore, I hereby consent to the release of information or reporting by the AMC/NOMA to its decision regarding my application as required by the AMC/NOMA’s constitution, bylaws or procedures, or as otherwise required by law.

I understand that membership classification will be determined by the Board of Directors. I have truthfully and fully answered all questions above and understand that I am obligated to notify the AMC/NOMA if any of the answers I have provided above do not remain true and correct.