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MEDICAL STUDENT/RESIDENT MEMBERSHIP APPLICATION

  
The Tennessee Medical Association and its chartered component medical societies are organizations for physicians licensed to practice medicine in Tennessee who care about the quality, enjoyment and profitability of their practices and the integrity of the profession of medicine. Membership entitles you to all advocacy, education and professional development resources.
     
Complimentary membership                  

PERSONAL

    
First Name
 Middle Name/Initial
 		 Last Name
Suffix
    
Gender
 Date of Birth
Last 4 of SSN
Medical School
 Graduation Year 
  
Designation
 TN Medical License # (if applicable)
 NPI #(if applicable)
     

MEDICAL PRACTICE

  
Primary Specialty
 Secondary Specialty
Practice County
  
   
 ADDRESS/COMMUNICATIONS INFORMATION (Please check the preferred address for Association correspondence)
Preferred Mailing Address  
  
 Work Address
    
Company or Practice
Address Line 1
 Address Line 2
  Address Line 3
City
 State
 Zip
Office Phone
 Office Fax
  
     
Home Address
    
Address Line 1
 Address Line 2
 Address Line 3
City
 State
 Zip
Home Phone
 Mobile Phone
  
     

(Please provide a personal or unique email to you, not a general practice email.)

      Consent to receive email from TMA

  
Email
 Confirm Email
  
User Name
 Password (minimum 6 characters)
 Confirm Password