KAM/TMA Membership Application
 
  * Required fields
  ** Required for Active Practice only
* Choose one:
  Active Practice
  Resident/Fellow
 
Personal data
* First name:
Middle name:
* Last name:
* Birth Date: (ie. mm/dd/yyyy)
 
  Male     Female
 
  MD     DO
* Birthplace:
* Social Security #: (Please use format: xxx-xx-xxxx)
Spouse's Full Name:
** TN Medical License #: (Please use format: 00000xxxxx)
** Date of Issue: (ie. mm/dd/yyyy)
 
Address Information
(Please check the preferred address for KAM/TMA correspondence)
 
Primary Office
 
  Preferred
* Address:
* City:
* State:
* Zip:
Practice/Group Name:
Practice Website:
 
Home Address
 
  Preferred
* Mailing Address:
* City:
* State:
* Zip:
 
Communications Information
(Please complete all that is required and select the preferred methods of contact)
  * Email:
  * Office Tel:
  Office Tel 2:
  * Fax:
  Pager:
  Cell Phone:
  * Home Tel:
  Home Fax:
 
Training
* Specialty:
Subspecialty:
* Medical School:
(Name of Institution, Location, Dates, Degree)
  Residency:
  Fellowship

(Name of Institution, Location, Dates, Degree)
  Residency:
  Fellowship

(Name of Institution, Location, Dates, Degree)
  Residency:
  Fellowship

(Name of Institution, Location, Dates, Degree)
Board Certifications:
  (Boards and Dates)
** Primary Hospital:
Secondary Hospital:
Organization Involvement:
Have you ever been convicted of a felony crime?
If yes, please provide full information.
  Yes     No

Has your license to practice medicine in any jurisdiction been limited, suspended or revoked?
If yes, please provide full information.
  Yes     No

I agree that all statements are true and complete to the best of my knowledge and belief. If elected to membership, I agree to conduct myself professionally and personally according tot he principles of medical ethics and be governed by the Constitution and bylaws of the local medical society, the Knoxville Academy of Medicine and Tennessee Medical Association, its officers, agents, employees, and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and hereby release from any liability any and all individuals, who, in good faith and without malice, provide information to the above named organizations, or to their authorized representatives concerning my professional competence, ethical conduct, character, and other qualifications for membership.
* Check this box to show your agreement with the above statement
* Date:
 
PAYMENT INFORMATION
Check the KAM/TMA Dues Categories Chart for Status Category and payment information
Status Category:
Amount of KAM/TMA dues: $
To apply for membership in the American Medical Association at this time, simply check the box
(optional)
AMA dues amount: $
AMA + KAM/TMA total dues: $
 
  Payment by check
  Make KAM/TMA dues check payable to the Tennessee Medical Association and mail to:
Tennessee Medical Association
c/o Membership Department
P. O. Box 440238
Nashville, TN 37244-0238
Total Check Amount: $
 
  Payment by credit card
Credit Card Type:
Mastercard   Visa   American Express
Company Name:
Company Phone Number:
EXACT name of Card Holder:
Credit Card Number:
Credit Card Holder's Billing Address:
Cardholder's Billing Zip Code:
Expiration date on card: Month/Year
Total Charge Amount:
   
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