Membership Application RequestPueblo County and Colorado Medical SocietyThank 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 Corporate Billing Address: PO Box 69, Dickinson, ND 58602 Fax to: 701-483-6534 If you should have questions, call 719-564-9109 and ask for the Executive Director
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