Osteopathic Foundation of West Michigan
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WMOA Membership Application
Applicant Information
Name
*
First Name
Last Name
Professional Level
*
select one
DO
MD
DO - Resident
PA-C
NP
RN
Medical Student
Other
AOA# (or N/A)
Practice Specialty
Family Medicine
Internal Medicine
OB/Gyn
Pediatrics
OMM
Emergency Medicine
Other
Other Specialty
Please describe your specialty if not listed above.
Membership Level
*
select one
Osteopathic Member (D.O)
Associate Member (M.D. or other provider)
Amount
*
$
Contact Information
Preferred Email
*
Verify Email
*
Preferred Phone Number
*
Home Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Organization/Employer
*
Employment Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Education and Certification Information
Medical School
*
(Or PA or NP program)
Internship/First-Year Residency
*
Enter N/A if indicated.
Residency
*
Enter N/A if indicated.
Board Certification
*
Enter N/A if indicated.
Health System Staff Membership
*
Enter N/A if indicated.
Licensures: List all licenses currently held.
*
State of Michigan Pharmacy License (current expiration date):
*
Narcotics License:
*
Federal DEA in effect?
Yes
No
If not, when was it revoked and why?
*
Have you ever been suspended temporarily or permanently from any health system? If yes, why and for how long?
*
Have you ever been convicted of a crime, other than minor traffic violations, or lost your license to drive?
*
Signature & Date
By entering my name, I signify that this is my electronic signature.
Applicant Signature:
*
Date
*
(mm/dd/yyyy)
Optional: Add 3% to my total amount to help cover the payment processing fees