Basic Information
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Professional Contact Information
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Professional Information
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Education and Training
NOTE: It is required that you enter a full Medical School record.
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Personal Information
Date of Birth*: MM/DD/YYYY
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Membership Agreement
I declare that should I be elected a member thereof, I agree to hold the North Bay County Medical Societies, its members, examiners, officers and agents free from any damage or complaint by reason of any action they or any of them may take in conjunction with this application.
I agree, in case of the election, that membership shall be conditional upon compliance with the bylaws of the North Bay County Medical Societies, as well as the Constitution and Bylaws of the California Medical Association; I further agree that I will recognize the authorized officer of North Bay County Medical Societies and the California Medical Association as the proper authorities to interpret any doubtful points in professional conduct and will at all times abide by their interpretation; I am aware that information submitted in this application and additional information obtained by the North Bay County Medical Societies will be verified. I hereby authorize other organizations having information relating to this application, including but not limited to hospital medical staffs, other medical societies, medical schools and governmental and regulatory entities, to release any and all such information to the North Bay County Medical Societies.
I declare under penalty of perjury that the above information is true to fact and that if any erroneous statements have been made, such statements shall be considered as just cause for cancellation of my membership in the North Bay County Medical Societies.

Payment Information
 
SCMS/CMA Membership Dues $0.00
 

Optional Dues and Contributions - RECOMMENDED:

We encourage your support in any of the following categories:



$ Alameda-Contra Contra Costa Physician's Committee-ACCPAC- (recommended contribution -$25)


$ CMA Political Action Committee (CALPAC) Membership

(Sustaining Member-$150 | 300 Club-$300 | Congressional Club-$500 | Presidents Circle-$1000)


$ CMA Physician Issues Committee (recommended contribution -$25)


$ NBCMS Medical Student Scholarship Program (recommended contribution -$25)

AMA now handles its dues directly. Information: (800) 262-3211; www.ama-assn.org

Click here for more information on tax deductability of dues and contributions.

*No more than $66 of CMA dues is directed to CALPAC, CMA's political action committee, to support candidates for public office who share CMA's philosophy. Members who object to this may check the box below and it will be re-directed to CMA's Independent Expenditure Committee, a fund for independent expenditures which does not directly contribute to candidates running for public office.

Please deposit my portion of dues into CMA's Independent Expenditure Committee.
 
 
TOTAL AMOUNT DUE: $0.00
 
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