RESIDENT CATEGORY, MEMBERSHIP APPLICATION - Pacific Dermatologic Association

MEMBERSHIP APPLICATION
RESIDENT CATEGORY

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: *

Expected Date of Completion: *
OTHER SPECIALTY TRAINING
Specialty:

Institution:

Location:

Dates:

VERIFICATION OF RESIDENCY
Name of Residency Director or Program Chair: *

CATEGORIES & DUES

		RESIDENT — $0 A resident shall be a physician who is in an accredited dermatologic resident training program. Upon completion of the program, residents can apply for membership as a Fellow or Associate member. Residents are not eligible to vote or hold office, but may serve on committees. Note: Any physician who joins within three (3) years of completing their dermatology residency may participate in a tiered dues plan, which brings their dues up to the full amount paid by other members by their fourth year after training. Note: Residents are not required to pay membership dues while participating in an accredited residency program and are able to register for the scientific portion of the Annual Meetings without charge (optional workshops, tours, not included).

IMPORTANT:

By pressing "Submit Membership Application" below, I do hereby assure that the entries and statements made on this application form are true and correct to the best of my knowledge.