Basic Information
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Professional Information
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Education and Training and Fellows
NOTE: It is required that you enter a full Medical School and Residency Program record.
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Personal Information
Date of Birth*: MM/DD/YYYY
Gender*: FemaleMale

Membership Agreement
I agree to conform to the bylaws of the Alameda-Contra Costa Medical Association.
I declare that should I be elected a member thereof, I agree to hold the Sierra Sacramento Valley Medical Society, its members, examiners, officers and agents free from any damage or complaint by reason of any action they or any of them may take in conjunction with this application. I agree, in case of the election, that membership shall be conditional upon compliance with the bylaws of the Sierra Sacramento Valley Medical Society, as well as the Constitution and Bylaws of the California Medical Association; I further agree that I will recognize the authorized officer of Sierra Sacramento Valley Medical Society and the California Medical Association as the proper authorities to interpret any doubtful points in professional conduct and will at all times abide by their interpretation; I am aware that information submitted in this application and additional information obtained by the Sierra Sacramento Valley Medical Society 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 Sierra Sacramento Valley Medical Society. I declare under penalty of perjury that the above information is true to fact and that if any erroneous statements have been made, such statements shall be considered as just cause for cancellation of my membership in the Sierra Sacramento Valley Medical Society.
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
 
2011 ACCMA/CMA Membership Dues $0.00
 

Optional Dues and Contributions - RECOMMENDED:

Specify contributions in boxes provided below. Your contribution is tax-deductible as allowed by law.



$ Alameda-Contra Contra Costa Physician's Committee-ACCPAC- (recommended contribution -$25)


$ 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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