Basic Information
Please enter your name:
First Name*
Middle Name
Last Name*
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Professional Contact Information
NOTE: It is required that you enter a Home Address and select a preferred address.
Home Address*:
Home Address cont.:
City*:
State*:
Zip*:
Phone*:
Fax:
Email*:
 

Professional Information
Primary Specialty:
 
Self-Designated Speciality:
 
 
 
 
Mode of Practice:
List the dates and location of medical practice since completion of your training. Please account for all gaps in your professional medical practice history.
What languages other than English do you speak?
(Ctrl + click to select multiple)
What languages other than English are spoken by a colleague or staff person in your office?
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Education and Training
NOTE: It is required that you enter a full Medical School record.
Degree Institution State Degree Year

Personal Information
Date of Birth*: MM/DD/YYYY
Place of Birth:
Sex*: FemaleMale
Spouse/Partner First Name:
Spouse/Partner Last Name:
Spouse/Partner Designation:

Membership Preferences
How do you prefer to receive ACCMA communications?
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How many complimentary copies of the ACCMA Membership Directory would you like to receive each year?
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Membership Agreement
I agree to conform to the bylaws of the Alameda-Contra Costa Medical Association.
I am aware that information submitted in this application and additional information obtained by the Alameda-Contra Costa Medical Association will be verified. I hereby authorize other organizations having information relating to this application, including but not limited to hospital medical staffs, other medical societies, medical schools and governmental and regulatory entities, to release any and all such information to the Alameda-Contra Costa Medical Association. I hereby authorize the Alameda-Contra Costa Medical Association to make known to hospitals and other medical organizations upon request any information the Association may have concerning me.
I understand and agree that acceptance of this application, application fees, and/or dues, does not constitute approval or acceptance of my membership.

Payment Information
 
ACCMA/CMA Membership Dues $0.00
 

Optional Dues and Contributions - RECOMMENDED:

We encourage your support in any of the following categories:



$ Alameda-Contra Contra Costa Physician's Committee-ACCPAC- (recommended contribution -$50)


$ CMA Political Action Committee (CALPAC) Membership

(Sustaining Member-$150 | 300 Club-$300 | Congressional Club-$500 | Presidents Circle-$1000)


$ CMA Physician Issues Committee (recommended contribution -$25)


$ ACCMA Medical Student Scholarship Program (recommended contribution -$25)

AMA now handles its dues directly. Information: (800) 262-3211; www.ama-assn.org

Click here for more information on tax deductability of dues and contributions.


*No more than $66 of CMA dues is directed to CALPAC, CMA's political action committee, to support candidates for public office who share CMA's philosophy. Members who object to this may check the box below and it will be re-directed to CMA's Independent Expenditure Committee, a fund for independent expenditures which does not directly contribute to candidates running for public office.

Please deposit my portion of dues into CMA's Independent Expenditure Committee.

 
 
TOTAL AMOUNT DUE: $0.00
 
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