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Membership Application
 
(* required field)
(** required for Active Practice only)
Choose One:     Active Practice        Resident/Fellow        Medical Student
Personal Data:
* First Name: Middle Name: * Last Name:
* Birth Date: (ie.mm/dd/yyyy)     Male  Female     MD  DO
* Birthplace:
* Social Security #: (Please use format: xxx-xx-xxxx)
Spouse's Name:
** TN Medical License #: (Please use format: 00000xxxxx)
** Date of Issue: (ie.mm/dd/yyyy)
** National Provider Identification   National Plan and Provider Enumeration System (NPPES)
Address Information: (Please check the preferred address for TMA correspondence)
Primary Office: Preferred
** Address:
 
** City: ** State:
** Zip:
Practice/Group Name:
Home Address: Preferred
* Mailing Address:
* City: * State:
* Zip:
Communications Information: (Please complete all that is required and select the preferred method of contact)
* Email: Pager:
** Office Tel: Cell Phone:
   Office Tel 2: Home Tel:
   Fax: Home Fax:
Training:
** Specialty:
Subspecialty:
* Medical School:
(Name of Institution, Location, Dates, Degree)
Residency
Fellowship
(Name of Institution, Location, Dates, Degree)
Residency
Fellowship
(Name of Institution, Location, Dates, Degree)
Residency
Fellowship
(Name of Institution, Location, Dates, Degree)
Board Certifications:
(Boards and Dates)
Organization Involvement:
Previous Medical Society Memberships:
Society:
City:
State:
From Date:
To Date:
 
Society:
City:
State:
From Date:
To Date:
Medical Specialty Society Information:
Memberships:
TMA provides representation in its policy body based on specialty society demographics of our members.
Of your specialty society memberships, which one of these organizations would best represent your specialty interests?
Have you ever been convicted of a felony crime? If yes, please provide full information.
Yes   No
Has your license to practice medicine in any jurisdiction been limited, suspended or revoked? If yes, please provide full information.
Yes   No
 
I agree that all statements are true and complete to the best of my knowledge and belief. If elected to membership, I agree to conduct myself professionally and personally according tot he principles of medical ethics and be governed by the Constitution and bylaws of the component medical society, the Tennessee Medical Association, its officers, agents, employees, and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and hereby release from any liability any and all individuals, who, in good faith and without malice, provide information to the above named organizations, or to their authorized representatives concerning my professional competence, ethical conduct, character, and other qualifications for membership.
* Check this box to show your agreement with the above statement.   * Date: (ie.mm/dd/yyyy)
We encourage you to apply for membership in the American Medical Association at this time by simply checking the box to the left.
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