Membership Application

 
   
Individual Information (to be displayed online)
AOA # *
FL License # *
Social Security # *
Designation (DO, MD, RN, etc)
First Name *
Last Name *
Office Address *
Address 2
City *
State *
Zip *
Phone *
Fax
Website
Email *
Date of Birth *
Spouse's Name
Billing Address (if different)
Street
City
State
Zip
Mailing Address (if different)
Street
City
State
Zip
Practice History
Please include and state any revocations of licence or privilege
Previous Practice (if any)
Hospital Staff (present)
Other State Licences
State: Licence#: Date:
State: Licence#: Date:
Education
Pre-Osteopathic Training
College
Degree
Year
Osteopathic Training
College
Year
Internship Program
Hospital
City
State
Dates From: To:
Residency Program
Hospital
City
State
Dates From: To:
Specialty/Certification
Specialty
Certification(s)
Disciplinary History

Have you ever been suspended, censored, disciplined or disqualified by any licensing or regulatory agency, professional association or society?

Have you ever been convicted of, or entered a plea of guilty, nolo contendre, or no contest to a crime in any jurisdiction other than a minor traffic offense?

Have you ever denied or surrendered a DEA registration or received a notice of administrative hearing from the DEA?

Membership Investment
Membership Type: *
Primary Directory Category *
   
Total: $ 

The contents of this box are for testing purposes. This box will be removed when the form goes live.
Full-Time Employees
Part-Time Employees
Hotel/Motel Rooms
Restaurant Seats
Additional Associates
Additional Associates Cost
Additional Locations
Additional Locations Cost
Assets
Assets Cost
AdditionalCategories
Additional Categories Cost
NumberOfAdditionalCategories
additionalItem1Cost
Annual Dues (charged to card)

Tax (charged to card)
Fee (charged to card)
tempValueForDropDown1
Additional Directory Categories
  • Primary Directory listing is complimentary
  • Up to two additional Directory listings are complimentary
  • After two, additional Directory listings are $35 each
**Hold CTRL on your keyboard to select multiple categories**
Number of Full Time Employees:  
Number of Part Time Employees:  
Number of Rooms (Accommodations):  
Number of Seats (Restaurants):  
Number of Associates (Realtors, Attorneys):  
Number of Locations ($35/add. location):  
Millions in Assets (Financial Institutions):  
$ 
$ 
$ 
Enhanced Membership ($50):
*
NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.
Credit Card Information
Credit Card Type *
Credit Card Number * 
Name On Card
Security Code
Valid Through
Credit Card Address 1
Credit Card City
Credit Card State
Credit Card Zip
Credit Card Phone Number
Credit Card Email Address

By my submission, I hereby agree to practice, comply, and govern my conduct in accordance with the code of ethics of the FOMA and such other standards of conduct and practice ethics adopted by the Association and application for membership in the FOMA.

I hereby authorize release of the information contained in this application and membership file to those organizations or hospitals to which I may subsequently apply for membership and the release to FOMA by organizations and hospitals of information relative to my previous membership in those organizations.

NOTE: It may take up to 2 business days for you to receive your FOMA Member username and password.

Please click submit only one time.  The transaction may take several seconds.

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Florida Osteopathic Medical Association (FOMA) | Tallahassee, FL