North Carolina Chapter North Carolina Pediatric Society Application for Physician, Student and Resident Membership
Name:
____________________________________ Degree:___________ Date:
__________________________ Home Zip Code with 4-digit extension __________________________________________(If you do not know the extension, please give us your street address so we may obtain the extension. This information allows us to identify which election district you live in for legislative mailing purposes)
If
your preferred mailing address is not the one listed above, please indicate
where you would like to ______________________________________________________________________________________________ The requirements of membership are at least two years of pediatric training or two years of practice limited to pediatrics. Those eligible may become members of the Society by either of two ways: I. Being a
Fellow or Candidate Fellow of the American Academy of Pediatrics or II. Being
recommended by two members of the Society and meeting the above qualifications. 1. (Name) (City): ___________________________________________________________________ 2. (Name) (City): ___________________________________________________________________
School and Date of Medical
Graduation:
___________________________________________________________
Description of Current Practice
(private, general, subspecialty, academic, HMO, public health, other)
_______
___________ Full Time: ____________ Part Time:
Medical License Number: _________________________ Annual
Chapter dues (made payable to the AAP*) = $180 for July 1-
June 30 North
Carolina Pediatric Society Phone: 919/839-1156 *The AAP is our dues billing agent for all physician members
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