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West Virginia State Medical Association
4307 MacCorkle Ave, S.E.
P.O. Box 4106
Charleston, WV 25364
ph. 304-925-0342 fx.304-925-0345
 
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Resident Physician Section Membership Application

To request membership as a resident in the West Virginia State Medical Association's Resident Section (WVSMA-RPS), please complete this form and submit.  You wil be invoice for the following dues:

West Virginia State Medical Association  -  $30
American Medical Association  -  $45

 
* Name: (full name-no initials)
* Preferred Mailing Address:
* City:
* State:
* Zip:
* Phone number:
Fax number:
* Date of Birth:
* Place of Birth:
* E-Mail Address:
* Medical School:
* Year Graduated:
* Residency Year (1st, 2nd, ect.):
* Name and Address of Residency Preogram:
* Specialty/Type of Residency:
Spouse's Name:
   
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