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Member Application

Name:
Birth date
Office Address
City:
State: Zip:
Office Phone:
Office Fax:
Email:
Home Address
City:
State: Zip:
Home Phone:
Home Fax:
   
Medical School:
Year Begin
Year End
   
Internship:
Year Begin
Year End
   
Residency:
Year Begin
Year End
   
Post Graduate Training

Total Years:
   
Dermatology Board Certification Yes No
Date

(If applying for Fellow or Affiliate Dermatologist status, please attach proof of certification by the American Board of Dermatology or the
American Osteopathic Board of Dermatology, or their international equivalents.)

Medical License Number
Date:

State(s)

Please describe your training in Mohs Surgery:

Membership Category for Which You are Applying:

Fellow_ Member
Affiliate Member (Dermatologist or Pathologist)
Associate Member
International Member
Resident Member
   
Full-Time/Part-Time Academic Affiliation:
Hospital Appointments:
Publications & Exhibits:
Membership in Other Professional Societies:
Research:

If the answer to any of the following questions is “yes”, please indicate complete details in the space below

A. Has your license to practice medicine in any jurisdiction ever been limited, Suspended, or revoked? Yes NO
B. Have your privileges at any hospital ever been suspended, diminished, revoked, or not renewed? Yes No
C. Have you ever been dismissed or resigned from a previous hospital medical staff? Yes No
D. Have you ever been denied membership or renewal thereof, or been subject to disciplinary action
in any local, state, or national medical society?		 Yes No
   
 
 
 

 
 

 Mailing Address: American Society for Mohs Surgery · Private Mail Box 391, 5901 Warner Avenue· Huntington Beach, CA 92649-4659
Phone:714-379-6262   Toll Free 800-616-ASMS (2767)   Fax:714-379-6272
Email: info@mohssurgery.org

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