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Basic Information

First Name*

Middle Name

Last Name*

Name as you would like printed
(i.e. B. James Smith, MD)

Title (MD/DO/PA)

Email Address*

Type of Membership* MD or DO
Student
Resident/Fellow
Physician Assistant

Practice Information

Type of Practice* C-Clinic or Group
H-Hospital
S-Solo
O-Other

Physicians Only - Limited Practice (Practicing fewer than 20 hours per week)

Other State Licenses

State	Number	Date Issued	Active

Primary Specialty*

Board certified Year(YYYY)

Secondary Specialty

Board certified Year(YYYY)

Third Specialty

Board certified Year(YYYY)

Fourth Specialty

Board certified Year(YYYY)

Practice Experience

Professional Societies

Primary Hospital Secondary Hospital

Address Information

Address Line 1* Address Line 2 City* State* Zip* Phone* Fax	Address Line 1 Address Line 2 City State Zip Phone Cell Phone
Preferred Mailing Address* OfficeHome

Additional Information

Gender* MaleFemale

Date of Birth* (mm/dd/yyyy)

Birth Place*

US Citizen

Spouse First Name Spouse Last Name

Website Login* (Please make note of your login and password. This will be used for future access to the WSMA website)

Website Password*

Retype Website Password*

Education

Disciplinary Actions

Have you had any judgments or settlements made against you in professional liability cases, or are there any pending? YesNo If yes, briefly describe	Have your privileges at any hospital ever been suspended, denied, diminished, revoked or not renewed? YesNo If yes, briefly describe
Have you ever been denied membership or been subject to disciplinary action in any medical organization? YesNo If yes, briefly describe	Has your license to practice medicine in any jurisdiction ever been limited, suspended or revoked? YesNo If yes, briefly describe

Final Terms and Conditions

Please read the following legal terms of application and check the box at the bottom if you accept.

I hereby apply for membership in the WSMA and agree to abide by its Bylaws and the Principles of Medical Ethics. In consideration of the WSMA processing my application for membership, I grant permission and consent for their obtaining verification of above information.

I hereby release, and hold harmless from any liability or loss, the WSMA, its officers, agents, employees and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications who, in good faith and without malice, provide information to the WSMA or to its authorized representatives concerning my professional competence, ethical conduct, character and other qualifications for membership.

I further release from liability the WSMA, its officers, agents, employees and members for the delivery of information to any third party as authorized herein, provided such delivery occurs prior to the acknowledged receipt, in the office of the WSMA, of a written notice of revocation of the release.

I accept

Dues Information

Thank you for your application to WSMA.

Dues Information

WSMA member dues are paid annually and are due on January 1.
Resident member dues year begins July 1 and ends June 30.

Physicians:
Full time active member: $535.00
Limited practice member (practicing fewer than 20 hours per week): $317.00
Second year in practice (completed training* two years ago): $293.00
First year in practice (completed training within 12 months of today): FREE

*Training is defined as "continuous formal postgraduate medical training."

Residents/Fellows:
Single year Resident membership: $25
Three year Resident membership: $50

Medical Students: FREE

Physician Assistants: $125.00

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