IDAHO MEDICAL ASSOCIATION AND LOCAL MEDICAL SOCIETY



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|-General- |

|Name: |Degree: |Gender: Male ( Female ( |

|Practice Office Name: |Office Phone: |

|Practice Office Address: |City: Zip: |

|Applicant Email*: |Office Fax: |

|Office Manager Name: |Office Manager Email: |

|Home Address: |City: Zip: |

|Home Phone: |Mobile Phone: |

|Home Email: |Home Fax: |

|Spouse Name: |Date of Birth: |

|Name of Employed or Supervising IMA Physician Member**: |

| |

|-Education/Professional Practice- |

|Idaho License Number: |Issue Date: |Expiration Date: |

|Specialty(optional): |

|-Membership Qualifications- |

|I agree to conduct myself professionally and personally according to the principles of medical ethics of the American Medical Association and the Idaho Medical Association|

|and to be governed by the Constitutions and By-Laws of the County Medical Society and the Idaho Medical Association. |

| |

|*By providing your email address you will be automatically subscribed to receive the majority of our communications via e-mail. An email address is required for accessing |

|IMA online services including dues payment, listing updates, or event/workshop registrations. Your email will not be released to any person or entity. To unsubscribe from |

|the email communications list, please email your request to membership@. |

| |

|**Physician assistants: Must be licensed with the Idaho State Board of Medicine and whose supervising physicians are members of this association. Nurse practitioners: Must|

|be licensed with the Idaho State Board of Nursing and who are employed or supervised by physicians who are members of this association. |

Applicant Signature: Date:

Remit to: P.O. Box 2668 * 305 W. Jefferson * Boise, Idaho 83701 * (208) 344-7888 * (208) 344-7903 *

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Idaho Medical Association

MEMBERSHIP APPLICATION/UPDATE FORM

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