Membership Application 

PERSONAL INFORMATION
First Name: *
Last Name: *  
Middle Initial:  
Office Address: *
Office City: *
Office State: *
Office Zip: *
Office Phone: *
Home Address:  
Home City:  
Home State: *  
Home Zip:  
Home Phone:  
Fax:  
E-mail:  
Social Security Number:  
Birth Date:  
Gender:
Spouse:  
 

EDUCATION AND PROFESSIONAL INFORMATION
Medical School Graduated From:  
Medical School Date of Graduation:  
Degree (MD or DO):  
Residency Training Location:  
Inclusive Dates:  
Residency Training Location:  
Inclusive Dates:  
Nebraska Medical License Number:  
Primary Specialty:  
 

MEMBERSHIP APPLICATION AND QUALIFICATION QUESTIONS
Have you ever been convicted of fraud or a felony? *
Have you ever been the subject of any disciplinary action by any medical society, hospital medical staff or a State Board of Medical Examiners? *
Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine? This includes actions involving revocation, suspension, limitation, probation, or any other imposed sanctions or conditions. *
Have judgements been made or settlements required in professional liability cases against you? *
Have you ever had an application for membership in a County Medical Society rejected or revoked? *
 
If you answered yes to any of these questions, please explain, giving full details for each. I certify that the information in this application is accurate and complete.