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

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 _________________________________________________________

_________________________________________________Phone __________ Fax _________

City/State/Zip

Prior Practice Address ___________________________________________________________

_________________________________________________Phone __________ Fax _________

City/State/Zip

Home or Mailing Address ________________________________________________________

_________________________________________________Phone __________ Fax _________

City/State/Zip

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