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Maine Osteopathic Association Membership Application

	* - Indicates a required field
Applicant Information
*	First Name:
	Middle Name:
*	Last Name:
	Maine Osteopathic Lic. No.:
	Date Issued:
	AOA Number:
Business Information
*	Address:
*	City:
*	State:
*	Zip:
*	Telephone:
*	Fax:
*	E-mail address:
	Office Manager:
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:

	Practice Locations and Dates:

Educational Information
*	Pre-Osteopathic College:
*	Graduated Date:
*	Degree:
*	Osteopathic College:
*	Internship Completed at:
*	Residency Completed at:	Year:
*	Specialty Certification:	Year:
	HOSPITAL STAFF MEMBERSHIP (Please indicate current hospital membership with location, dates, type active, consulting, courtesy) and titles of any official positions held.

Personal Information
*	Home Mailing Address:
*	City:
*	State:
*	Zip:
*	Home Telephone:
*	Are you a US Citizen?	YesNo If not, where?
*	Marital Status:
	Spouses Name:
Military Service Information
	Service Branch:
	Discharge Rating or Rank:
	Date of Discharge:
	This document will not be "signed" in the sense of a traditional paper document. To verify the contents of this form, the signatory must enter any combination of alpha/numeric characters that has been specifically adopted to serve the function of the signature, preceded and followed by the forward slash (/) symbol. Acceptable "signatures" could include: /john doe/; /jd/; and /123-4567/. For example: if your name is John Doe , you could type /John Doe/ below.

*	Signature:

Please Note: For security reasons certain information is not collected online through this form. Specifically Date and Place of Birth. Please send them and any other supporting information needed to complete your application to:
Maine Osteopathic Association 693 Western Avenue, # 1 Manchester, Maine 04351 Or Phone: (207) 623-1101 Fax: (207) 623-4228