Please complete the requested information below and then click on the "Submit Application" button at the bottom.

If you are paying online via PayPal please select this button:

If you are paying by check, please send your payment of $150.00 to:
     Membership Chairperson
     Old Dominion Medical Society
     P.O. Box 74428
     Richmond, Virginia 23236

If you are paying by credit card, the Membership Chairperson will contact you once your application is received to take the necessary information.

Application
	Name:
	Business Address:
	Home Address:
	Telephone:
	Fax:
	E-mail:
	Date of Birth:
	Place of Birth:
Education
	Undergraduate:
	Degree:
	Date:
	Graduate:
	Degree:
	Date:
	Internship:
	Hospital:
	Date:
	Residency:
	Hospital:
	Date:
	Fellowship:
	Hospital:
	Date:
	Specialty:
	Board Eligible       Board Certified
	Date:
	Subspecialty:
	Board Eligible       Board Certified
	Date:
Medical Practice Date
	Date Began Practice in Virginia:
	State License Number:
	Other State License(s):
	Hospital Affiliation(s):
	Academic Appointment(s):
	Professional Membership(s):
	Activities or areas of special interest with the ODMS:
	Method of payment: check      credit card      Paypal (If you are paying by check, please send your payment to the address at the top of this form. If you are paying by credit card, someone from the Membership Committee will contact you to take the necessary information.)