Membership Application

Individual Information (to be displayed online)

AOA # *

FL License # *

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: Required Please enter a valid number Please enter a valid date	Licence#: Required Please enter a valid number Please enter a valid date	Date: Required Please enter a valid number Please enter a valid date
State: Required Please enter a valid number Please enter a valid date	Licence#: Required Please enter a valid number Please enter a valid date	Date: Required Please enter a valid number Please enter a valid 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?

No

Yes

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?

No

Yes

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

No

Yes

Membership Investment

Membership Type: *

Primary Directory Category *

Annual Membership Investment

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)

Revenue Item

Tax (charged to card)
Fee (charged to card)

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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):

Additional Categories Cost

$

One-Time Application Fee

$

Tax

$

Enhanced Membership ($50):

Membership/Payment Type *

Payment Type

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 *

Mastercard

Visa

Discover

Amex

Credit Card Number *

Name On Card	Required
Security Code	Required
Valid Through
	Use Address Above
Credit Card Address 1	Required
Credit Card City	Required
Credit Card State
Credit Card Zip	Required
Credit Card Phone Number	Required
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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