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:
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.