Application for Membership

Membership Application

Thank you for your interest in joining The Bays Medical Society. We welcome all physicians (MDs and DOs) who practice in, reside in, retired from practice in, or visit Bay County, Florida.

Please complete the following information:

Complete Name

Credentials (MD or DO)

Organization or Practice Name

Street Address

Mailing Address

City (for mailing address)

State

Zip Code

Spouse or Significant Other

Office Phone

Home Phone

Cell Phone

Fax

Email

Website (if you have one)

Date of Birth

Gender Male Female

Are you in active practice of medicine? Yes No

Are you inactive from the practice of medicine? Yes No (if yes, specify reasons in comments section, below)

Have you ever, in any jurisdiction:

been convicted of a fraud or a felony?
had any action taken against your license to practice medicine?
This includes actions involving revocation, suspension, limitation, probation, or any other sanctions or conditions.
been the subject of any disciplinary action by ay medical society or hospital medical staff?

PLEASE EXPLAIN ANY AFFIRMATIVE ANSWERS IN COMMENTS SECTION, BELOW.

Add any comments you feel may be relevant to this application. Feel free to include comments about how The Bays Medical Society can assist you and your practice, what educational offerings you'd like to see, and how you'd like to become involved in the Society.

The application will not be accepted as complete until membership dues are received.
Select payment Method:
Click here for payment instructions.

By submitting this application, I am aware that the information submitted in this application will be verified. I hereby authorize other organizations having information relating to this application, including governmental and regulatory entities, to release any and all such information. I understand that any false or misleading statement made on my application may be grounds for denial of membership or probation or censure by, or suspension or expulsion from the medical society.

If you have any questions, please contact our office.

submitted on: mm/dd/yy