The Medical Society of the County of Albany, Inc.

Members

The Benefits of Membership

Member Sites

Officers & Staff

Benefits

Member Application

Medical Society of the County of Albany
One Executive Centre Drive, Suite 201
Corporate Plaza, Albany, NY 12203

Medical Society of the State of New York
420 Lakeville Road, Lake Success, NY 11042

I also wish to apply to the American Medical Association, 515 North State Street, Chicago, IL 60610
Yes No

DATE
Year
Name: Sex:

Office

Street:

City:

State:

Zip:

Telephone:

Residence

Street:

City:

State:

Zip:

Telephone:

For Mail

Street:

City:

State:

Zip:

Birth

City:

State:

Country:

Date: Year

MARITAL STATUS

Married: Yes No

Spouse's Name:

Has your license to practice medicine ever been denied, suspended or revoked by any government agency?
Yes No

If yes, indicate where, when, and why.

Have you ever been a member of another county medical society in New York?
Yes No

If so, please indicate which one

Date licensed in New York:	Year:
License Number:

Board Certified: Yes No Date:	Year:
If certified, what board?

Workers' Compensation Board Rating:
Date of Rating:	Year:
Number:
Professional Corporation (PC)?	Yes No

Record of Medical Education and Practice

MEDICAL EDUCATION

College:
Date:	Year:
Degree:

Medical College:
Date:	Year:
Degree:

Chronological account of applicant's training, military service and practice since graduation from medical school. Include internship, residency and postgraduate study. Please leave no unexplained interval in sequence of dates, or attach explanation.

				Date
	Hospital	Service	Position	From	To
Most recent




Most distant

Present Hospital and Clinic Affiliation:

National Medical Association Membership:

The Medical Society of the County of Albany
One Executive Centre Drive · Suite 201, Corporate Plaza Albany, NY 12203
Tel: (518) 456-8571 · Fax: (518) 456-8573