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Physician Membership Application

Personal Information

First Name *

Middle Name

Last Name *

Maiden Name

Home Address *

Home City *

Home State *

Home Zip *

Cell Phone

Home Phone *

Home Fax

Home Email *

Birth Date

Month

Day

Year

Gender

Male

Female

Spouse

Referred By

Practice Information

Office Name

Office Address *

Office City *

Office State *

Office Zip *

Office Phone *

Office Fax *

Office Email *

Education Information

Medical School *

Medical School Graduation Date *

Month

Day

Year

Degree Obtained *

MBBS

Internship Location

Internship Dates

Specialty/Focus

Residency 1 Location

Residency 1 Dates

Specialty/Focus

Residency 2 Location

Residency 2 Dates

Specialty/Focus

Fellowship Location

Fellowship Dates

Specialty/Focus

Professional Information

Nebraska Medical License Number *

Medical Education Number

Board Certifications

Primary Specialty *

Secondary Specialty

Discliplinary Information

Have you ever had an application and/or membership in a Medical Society rejected or revoked? *

Yes

Have you ever been convicted of fraud or a felony? *

Yes

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. *

Yes

Have you ever been the subject of any disciplinary action by any medical society, hospital medical staff or a State Board of Medical Examiners? *

Yes

Have judgements been made or settlements required in professional liability cases against you? *

Yes

Are there any current suits or claims pending against you? *

Yes

If you answered yes to any of these questions, please explain full details for each.

Preferred Contact

Where should we send communications? *

Home

Office

Where should we send your annual dues statement? *

Home

Office

What is your preferred email address? *

Home

Office

Attestation

This application serves as my request for membership in the Nebraska Medical Association (NMA). I certify that the information in this application is accurate and complete. *

Yes