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Membership Application
Date of Application
Name (First/MI/Last)
Date of Birth
Social Security Number
Preferred Mailing Address
City
State
Zip Code
Sex
Work Phone
Home Phone
Fax
Email
Texas License Number
Specialty
College
City/State
Degree/Major/Date
Medical School
City/State
Degree/Date
Internship/Program
City/State
Dates
Residency/Program
City/State
Dates
Fellowship/Program
City/State
Dates
Board Certification:
Primary Specialty/Date
Subspecialty/Date
Mode of Practice (Academic/Group/Solo/Government)
Other Professional Organizations
Fraternal/Social/Advocacy Organizations
Spouse’s Name
Please select preferred contact method:
Fax
Mail
Signature
Dues schedule (include no money now; we will send invoice upon acceptance)
Practicing physician $250/year
First year of practice $50/year
Resident/Fellow $25/year
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