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?
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.