Monday, December 11, 2017
 
 

Please select appropriate membership category. Return to Membership Category explanation.

Now Through 11/30/2017, take advantage of our special half price offer on first year membership and active previous member rejoin.








Please complete items applicable to your membership category.

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First Name Middle Last Name MD/DO/Other

Date of Birth Medical School Graduation Date

Home Address

City State Zip Code

Home/Cell Phone Preferred Email Address

Active/Non-Resident/Associate/Health Care Administrator Members, please complete the following:

Practice/Group Name Web Address

Primary Office Address

City State Zip Code

Primary Office Telephone Office Fax

Primary Specialty Board Certification Secondary Specialty Board Certification

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Preferred Mailing/Billing Location:

If accepted as a member, I agree to abide by the Academy of Medicine of Cincinnati Articles of Incorporation and Code of Regulations. I understand and agree that by providing my address, email(s), telephone numbers(s), and fax number(s), I consent to receive communications sent by or on behalf of the Academy of Medicine of Cincinnati via regular mail, email, telephone, or fax.

By checking I agree to the terms and conditions above.

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