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