Maine Osteopathic Association Membership Renewal

	* - Indicates a required field

Applicant Information
*	First Name:
	Middle Name:
*	Last Name:
	Maine Osteopathic Lic. No.:
	Date Issued:
	AOA Number:
*	MOA Number:
Business Information
*	Address:
*	City:
*	State:
*	Zip:
*	Telephone:
*	Fax:
*	E-mail address:
	Please update any of the information below that has changed since your last membership application/renewal.
Practice Information
*	Specialties Practiced:
*	Please indicate the level of OMT you do in your practice:
*	Current Practice Status:
	Membership Fees (Membership Year is June 1 - May 31)	Student - $0.00 Intern or Resident - $0.00 First Year Practice - $132.00 Second Year Practice - $263.00 Full Member - $394.00 Retired - $60.00 Out of State Member - $198.00
	Other State Licenses Held:

Educational Information
*	Osteopathic College:
	Internship Completed at:
	Residency Completed at:	Year:
	Specialty Certification:	Year:
Optional Support
	MOEF Amount:	$50 $100 Other
	MOPAC Amount:	$50 $100 Other
MOA Communication Preference
	Preference:	Email Fax Mail

*	Signature:

Maine Osteopathic Association 693 Western Avenue, # 1 Manchester, Maine 04351 Or Phone: (207) 623-1101 Fax: (207) 623-4228