MEMBERSHIP APPLICATION - Pacific Dermatologic Association

MEMBERSHIP APPLICATION

CONTACT INFORMATION
* Required
Date: *

Full Name: *

Degree(s):

Mailing Address: *

City: *

State: *		(Province or Other)

Zip: *

Country: *

Telephone: *

Fax:

Email: *

Birthdate: *

Citizenship: *

Academic Affiliation (If Any):

EDUCATION
* Required
MEDICAL SCHOOL *
School: *

Location: *

Degree: *

Dates: *
OTHER GRADUATE SCHOOL
School:

Location:

Degree:

Dates:
DERMATOLOGY RESIDENCY (Postgraduate Training)
Institution:

Location:

Dates:
OTHER SPECIALTY TRAINING
Specialty:

Institution:

Location:

Dates:

CERTIFICATION
American Board of Dermatology: (Year)

American Osteopathic Board of Dermatology: (Year)

Foreign Dermatology Board or Examination
Name of Board or Examination:

Year

Other Specialty Board
Name of Board or Examination:

Year:

CATEGORIES & DUES
Please check category for membership for which you are applying: (check one category; see definitions of categories below)
		FELLOW — $175 Any physician who is a resident of an eligible state or country and who has been certified by the American Board of Dermatology; or by equivalent examination in dermatology in another country.
		ASSOCIATE — $175 Any physician who is a resident of an eligible state or country, who has training which qualifies them for the examination of the American Board of Dermatology or an equivalent examination in dermatology in another eligible country.
		AFFILIATE — $175 Any physician who is a resident of an eligible state or country, in the following categories: a) Practicing dermatopathologists who are not eligible to be Fellows or Associates; b) Osteopathic dermatologists who are certified by the American Osteopathic Board of Dermatology but whose training does not make them eligible to be Fellows or Associates; or c) Physicians devoting the major portion of their time to the practice of dermatology, public health work, research, or education in connection with this specialty.
		Membership Eligibility: MEMBERS shall be drawn from physicians in good standing practicing in Alaska, Arizona, California, Colorado, Hawaii, Idaho, Kansas, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Utah, Texas, Washington, Wyoming, Mexico, that part of Canada comprising Alberta and British Columbia, and all Pacific Rim countries including, but not limited to Australia, China, Japan, New Zealand, Malaysia, the Philippines, North and South Korea, Singapore, Taiwan and Vietnam. An applicant for membership shall have resided within the geographic area of the PDA for not less than one year after completion of formal training and/or moving into this area.