Members - Membership Application

CENTRAL OHIO PEDIATRIC SOCIETY

5383 Stratford Ave.

Powell, OH 43065

Phone: (614) 722-5265

MEMBERSHIP APPLICATION

Last Name______________________________________First__________________MI______

Office Address_________________________________City___________State_____Zip______

Home Address_________________________________City___________State_____Zip______

Office Telephone_________________________Home Telephone________________________

Fax #_______________________________E-Mail__________________________________

For Mailing: _________ Use Office Address __________ Use Home Address

_____________________________________________________________________________

EDUCATIONAL:

Medical School___________________________________   Year Completed ________

Internship________________________________________ Year Completed ________

Residency________________________________________ Year Completed ________

Other____________________________________________ Year Completed ________

SPECIALITY BOARD QUALIFIED:

_________________________________________               Year Completed________

________________________________________________   Year Completed________

SPONSORS: (TWO ACTIVE COPS MEMBERS)

(1)______________________________________________________________

(2)______________________________________________________________

_____________________________________________________________________________
FOR OFFICE USE ONLY
1st reading:_________
Credentials Committee:__________
2nd reading:_________
Dues & Membership Materials Mailed:__________