Cobb County Medical Society

Please print, complete and mail to: 
Cobb County Medical Society, Inc. 
P.O. Box 1208 
Marietta, GA 30061-1208 
Attn: New Membership Application
 
Application for Membership


____________________________________________
Name
___________________________________
Social Security
________________________________________
Birth
_______________________
Spouse
________________________________________
Office Address
________________________________________________________________________________
Group Name
 
________________________________________________________________________________
Street Address							Suite Number

City__________________________  State_______  Zip___________

Telephone  _____________________________ Fax  _________________________


Home Address

_____________________________________________________________________
Street Address
 
City__________________________  State_______  Zip___________
 
 
Telephone  _____________________________ Fax  _________________________

Email Address _______________________________________________________
 
Specialty
Primary_______________________________________ Secondary____________________________________
 
Board Certification____________________________________________________________________________

Georgia License Number  _________________________
     		Expiration__________________________

Medical School Attended
_________________________________________________________________________
Name
 
_________________________________________       ______
City						State
 
 
Present Hospital Staff Privileges
	Hospital						Type
					     Active, Associate, Courtesy, etc.
_____________________________			_____________________________
 
_____________________________			_____________________________
 
_____________________________			_____________________________
Residencies, Internships & Fellowships:
Name									Date
____________________________________________________________	_________________

____________________________________________________________	_________________

____________________________________________________________	_________________

Disciplinary actions taken against Applicant by hospitals at which Applicant presently has
staff privileges (please describe)
_________________________________________________________________________________________

_________________________________________________________________________________________


Disciplinary action taken against Applicant by other hospital(s) at which Applicant had
staff privileges (please describe)
_________________________________________________________________________________________

_________________________________________________________________________________________


Disciplinary actions taken against Applicant by Composite State Board of Medical Examiners
or other licensing body (please describe)
_________________________________________________________________________________________

_________________________________________________________________________________________


Any drug or alcohol abuse, past or present? (please describe)
_________________________________________________________________________________________

_________________________________________________________________________________________

Do you accept new Medicaid patients?
Yes ____
No ____
 
Medicare Assignment?
Yes ____
No ____
 
Do you participate in HMO or PPO 
plans?
Yes ____
No ____
 
Do you have evening office hours?
Yes ____
No ____
 
If so, please list: 

_______________________________________________________________

Do you have weekend office hours?
Yes ____
No ____
 
If so, please list: 

_______________________________________________________________

Foreign Languages - please list:
 
________________________________________________________________________________________________


The undersigned applicant:
 
hereby certifies that all of the information contained in the application is true and correct;

hereby authorizes the Cobb County Medical Society, and its authorized representatives to consult
with any and all persons and obtain any and all documents necessary to verify the accuracy of
the information contained in this application;

hereby releases the Cobb County Medical Society, and its authorized representatives and all
persons and organizations who provide information to the Cobb County Medical Society or its 
authorized representatives in accordance with this application from any liability arising out 
of the above described authorization actions;

hereby agrees to promptly notify the Cobb County Medical Society, in writing, in the event 
of a material change in any of the information provided by the Applicant in this application.
 
This  _________  day of ____________________  2008
 
__________________________________________________
 
Applicant Signature