Winnebago County Medical Society


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Membership Application

Personal Information

Physician Resident Student

Degree: MD DO JD MBA Other

Gender: M F

First Name
Middle Name
Last Name
Birth Date	(mm/dd/yyyy)
Place of Birth
Social Security Number
Spouse
Home Address
City
State
Zip
Telephone
Fax
E-mail
Office Address
Address Cont.
City
State
Zip
Telephone
Fax
E-mail
Preferred Mailing Address: Office Home

Professional Information

Primary Medical Specialty
Medical Subspecialty
Other Areas of Practice
Medical School
Year of Graduation
City
State/Province
Country
Internship
Specialty
Dates attended
City
State/Province
Residency
Specialty
Dates attended
City
State/Province
Country
Fellowship
Specialty
Dates attended
City
State/Province
Country

American Board
Eligible: Yes No \| Certified: Yes No

American Board
Eligible: Yes No \| Certified: Yes No

Prior Practice: (city, state)
From (year) To (year)
State of Illinois License Number
Other State Licenses

Application and Qualification Questions

Members support the Winnebago County Medical Society and Illinois State Medical Society Bylaws and Code of Medical Ethics. To assist us in upholding these standards, please provide answers to the following questions, sign and date. If you answer yes to any of these questions, please provide additional information.

Have you ever been convicted of fraud or felony?
Yes No

Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine? This includes actions involving revocation, suspension, limitation, probation, or any imposed sanctions or conditions.
Yes No

Have you ever been denied membership or been subject of any disciplinary action by any medical society or hospital medical staff?
Yes No

I am aware that 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(ies).

The forgoing information is true and complete.

Name
Date (mm/dd/yyyy)

If you are joining the medical society at the suggestion of a current member, we would appreciate the opportunity to thank him/her. Please indicate the member who referred you:

Name of Member

Thank you for applying for membership in the Winnebago County Medical Society.

This application may be printed and mailed to the address below.

If you have any questions or need assistance, contact us at:

Winnebago County Medical Society
6991 Redansa Drive
Rockford, IL 61107
Phone: 815-395-(wcms)9267
Fax: 815-484-4109
E-Mail: WCMS1@aol.com

Educational Opportunities

Community Outreach

Membership Development