Membership Application

Homeopathic Medical Society of the State of New York — Est. 1862

Please provide your contact information

Homeopathic Medical Society of the State of New York

Please add your professional details

Homeopathic Medical Society of the State of New York

Please share your other interests

Active Members- Complete all details. For students, residents and interns, skip to Agreements.

Active Members- Complete all details. For students, residents and interns, skip to Agreements.

Active Members- Complete all details. For students, residents and interns, skip to Agreements.

Active Members- Complete all details. For students, residents and interns, skip to Agreements.

To be completed by all applicants

  • Contact Info
  • Professional
  • Interests
  • Background
  • Practice
  • Other
  • References
  • Agreements

Contact Information

Date:

Name:

Email address:

Repeat to confirm

Website:

Office Address

Street:

City:

State:

Zip:

Office Phone:

Home Address

Street:

City:

State:

Zip:

Home Phone:

Credentials and Practice

Degrees

New York Licenise #:

In what other states are you licensed to practice?

Type of Practice:

Interests

Homeopathic Interests:

Special Interests:

Membership Type

Class of Membership Desired and Annual Fees:

Birth and Citizenship (required for full membership)

Date and place of birth:

Citizenship:

If naturalized, give date and certificate number:

Education (required for full membership)

Undergraduate college or university:

Undergraduate degree and year:

Name of medical school and year graduated

Graduate Training (required for full membership)

Internship—Hospital, Type of service and dates of service

Residencies (list all)—Hospital, Type of service and dates of service:

Fellowships)—Hospital, Type of service and dates of service:

Additional Education (required for full membership)

Homeopathic Education:

Training in your specialty if not included in the above (where obtained and dates):

Certification (required for full membership)

Specialty board(s) and date(s) of certification:

If not board certified, are you eligible for board certification?

Appointments (required for full membership)

Hospital, courtesy:

Hospital, attending:

Teaching (give title and school with dates):

Professional Societies—If you have been or are a member, give name, dates and class of membership where appropriate (required for full membership)

Local medical society:

State or country medical society:

Professional societies (specialty or others):

Diplomate, American Board of:

American college of physicians:

American college of surgeons:

American college, associate of (name and date):

American college, fellow of (name and date):

Elected positions in medical societies:

Practice (required for full membership)

Exclusive of hospital and/or other training, for what period have you been engaged in practice?

If a specialist, how long have you practiced your speciality?

How long have you practiced in your present location?

Have you practiced elsewhere? If so, give locations and dates:

Type of Practice:

Other type of practice:

Other (required for full membership)

Have you ever been denied licensure in any state?

Explain denied licensure fully and give current status of license involved:

Have you ever had your license revoked?

Explain revoked licensure fully and give current status of license involved:

Are you currently or have you ever been investigated by the OPMC?

Explain OPMC investigation and give current status of license involved:

Are you engaged in any governmental position, business, trade or profession other than the practice of medicine?

Please specify your non-medical engagement:

Clubs of which you are a member other than professional:

Publications (Give title, journal, volume, year, page, authors.) Can also be uploaded as a separate document with this application.

References--List two. One may be an HMSSNY member. (required for full membership)

Reference 1: Name and complete address

Reference 1: In what capacity known:

Reference 1: How long known:

Reference 2: Name and complete address

Reference 2: In what capacity known:

Reference 2: How long known:

Additional Documents to submit with application

For Active, full memberships, please upload a copy of your NY State License

Max. size: 300.0 MB

For student/resident/intern memberships, please upload a copy of your student ID or letter from program director

Max. size: 300.0 MB

Additional upload materials to be considered with this application

Max. size: 300.0 MB

Agree & Sign

I request membership in the Homeopathic Medical Society of the State of New York. I have added or intend to add to my knowledge of medicine a knowledge of homeopathic therapeutics and observe the

To the best of my knowledge I have answered the above questions fully and honestly. I agree to abide by the bylaws of the Homeopathic Medical Society of the State of New York, to pay all dues, fees and assessments in a timely fashion, and to Conduct my practice in an ethical manner.

Type your full name in lieu of your signature:

Date of agreement: