Cobb County Medical Society Complete and mail with dues check for $165 to: Cobb County Medical Society, Inc. 114 Cherry Street, Suite D Marietta, GA 30060 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  _____________________________ Cell or Pager  _________________________ 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 ____________________  2011   __________________________________________________   Applicant Signature