MEMBERSHIP APPLICATION REQUEST

                                          

                                              Pueblo County 
                                                       and                                  
                                     Colorado Medical Society


Thank you for requesting an application for membership in the Pueblo County Medical Society (PCMS) and the Colorado Medical Society (CMS).

Completion of our application includes membership in the Pueblo County Society or Pueblo County/Colorado State Society. Please complete the following questionnaire so we can determine your applicable dues structure.

Name ________________________________________ MD DO (local membership only for PA/NP/DPMs) 

Are you relocating to Colorado? NO YES Date ________

Have you been in practice for two or more years? NO YES

If practicing less than two years, when did you complete your training? (mo/year)________


Practice Address (City/State/Zip)___________________________________________ ____________________________________________________
Phone __________ Fax _________


Prior Practice Address (City/State/Zip) __________________________________________________________________________________

Phone __________ Fax _________

Home or Mailing Address (City/State/Zip )____________________________________________________ _________________________________________________

Phone __________ Fax _________


Choose one of the following according to the time of the year you wish to join:

Send dues rates for: (Dec-Mar) (Apr-Jun) ( Jul-Sept) (Oct-Nov)

If you wish to be a member of the County Society ONLY please check: NO YES

If you wish to be a member of both County & State, please check: NO YES

Please return this request for application form via mail or fax to:
Pueblo County Medical Society
Corporate Billing Address
1925 E. Orman Ave - A448, Pueblo, CO 81004
or by Fax to: 866-468-5793
If you should have questions, call 719-281-6073 and ask for the Executive Director

You may also go to our links and use the online appication under Membership Application

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