Kane County Medical Society Application for Membership
Applicant Information
Check all that apply *
Degree *
Additional Credentials
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Gender *
Last Name (as shown on medical license) *
Your answer
First Name *
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Middle Initial *
Your answer
Spouse’s Last Name (if applicable)
Your answer
Spouse’s First Name
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Home Address *
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City *
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State *
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Zip *
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Cell Phone
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Receive text messages?
Primary E-mail *
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Birth Date *
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Place of Birth *
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Medical License Number *
Your answer
Medical Education Number (if known)
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Medical School Name *
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Medical School City *
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Graduation Year *
Your answer
Maiden Name (if applicable)
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Primary State of Licensure *
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Other State Licenses
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Primary Specialty *
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Board Certified *
Practice Name *
Your answer
Office Address (primary) *
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Office City *
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Office State *
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Office Zip *
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Practice Manager Name *
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Practice Manager E-mail *
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Office Telephone *
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Office Fax *
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Doctor’s Office E-mail
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Beginning Year of Practice *
The year you began active practice.
Your answer
Hospital Affiliations *
Your answer
Preferred Email Address *
Preferred Mailing Address *
Membership Application and Qualification Questions
Members abide by the ISMS Code of Medical Ethics and bylaws of the Society. 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 attach full information.
Have you been convicted of fraud or a felony?
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?
Have you ever been the subject of any disciplinary action by any medical society or hospital medical staff?
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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 foregoing information is true and complete.

Signature *
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Permission to send: Due to the federal communication regulations, it is necessary for MCMS to obtain consent to distribute information via fax and e-mail. By checking the boxes and providing your fax and email address, you agree to receive emails and facsimiles, including meeting and seminar information, manager programs and events and services offered by the Kane County Medical Society. *
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Date
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McHenry County Medical Society
2320 Dean Street, Suite 106, St. Charles, IL 60175
P: 630-584-7173 - F: 630-584-6703
www. mchenrymed.org
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