Application For Membership to

The Hudson County Medical Society and

The Medical Society of New Jersey

Name

(Exactly as on NJ Medical License)

Medical Education Number

( If ME# unknown, leave blank )

NJ Medical License#

Date Issued

Birth Date

Sex

Send Mail to: c Primary Practice c Secondary Practice c Home

Primary Practice		( )
	GROUP-NAME (if applicable)	TELEPHONE NUMBER
		( )
	STREET	Fax Number

	CITY, STATE, ZIP

Secondary Practice		( )
	GROUP-NAME (if applicable)	TELEPHONE NUMBER
		( )
	STREET	Fax Number

	CITY, STATE, ZIP

Home Spouse's Name		( )
	STREET	TELEPHONE NUMBER
		( )
	CITY, STATE, ZIP	FAX NUMBER
		E-mail Address

Past MSNJ member: No

Yes

County:

Current AMA Member: Yes

Medical Education
	School/Location		Degree		Year

Residencies/Dates

Fellowship/Dates

Specialty Areas - Primary

Secondary (if any)

Board Certifications

List any specialty societies in which you are a Fellow

Active Hospital Appointments

Please answer the following. Attach a full explanation to any questions answered "yes"

Have you ever been convicted of a crime? Has your license to practice medicine in any jurisdiction ever been limited, suspended or revoked? Have you ever been subject to any disciplinary action by any licensing board, medical society or hospital?
	Yes	No
	Yes	No
	Yes	No

I hereby release, and hold harmless from any liability or loss, the Hudson County Medical Society and Medical Society of New Jersey, their officers, agents, employees, & members for acts performed in good faith & without malice in connection with evaluating any application & my credentials & qualifications, & hereby release from any liability any & all individuals & organizations, who, in good faith & without malice, provide information to the above named organizations, or to their authorized representatives, concerning my professional competence, ethical conduct, character & other qualifications for membership. Furthermore, I attest to the accuracy of information supplied on this application & understand that falsification of any information may result in denial or revocation of membership.

Applicant's signature:

Date

Return completed application to: MSNJ, Two Princess Rd., Lawrenceville, NJ 08648 Questions? 1-800-322-MSNJ

Staff Use Only

CUA

Section 1:

To be completed by county medical society staff

Applicant's name:

County :

Date application received:

Applicant recruited by:

AMA Profile obtained c via modem c requested from MSNJ

This applicant is being considered for new membership or reinstatement of membership as:

c associate member (non-licensed in NJ)

c active membership

c licensed resident membership

c active membership by transfer from

Section 2:

To be completed by county medical society membership review body

The		of the Hudson County Medical Society has reviewed this application and
in accordance with the By-Laws of the Medical Society of New Jersey it is hereby being submitted for review and action of the Committee on Credentials of the Medical Society of New Jersey.


Print Name		Title (within County Medical Society)

Signature		Date of Action

ATTACH AMA BIOGRAPHICAL INFORMATION FORM AND SUBMIT TO MEMBERSHIP DEPARTMENT, MEDICAL SOCIETY OF NEW JERSEY, TWO PRINCESS RD., LAWRENCEVILLE, NJ 08648-2302

Section 3:

To be completed by state medical society membership department staff

Date received				AMA Profile attached c yes
Reviewed By				Licensing action noted c yes c no

Sent for review by	c	District #		Judge		Date
	c	Credentialing Committee Chair				Date

Section 4:

If applicable, to be completed by District

I have reviewed the information on this application and find the applicant

c satisfactory for membership c unsatisfactory for membership for the reason(s) stated below:

Signature

Date

Section 5:

To be completed by the Chair, MSNJ Committee on Credentials

I have reviewed the information on this application and find the applicant

c satisfactory for membership c unsatisfactory for membership for the reason(s) stated below:

Section 6:

To be completed by MSNJ Membership Staff

Credential review received at Medical Society of New Jersey on