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Physician Application

MDMEDICNE
You will be notified of the status of your application within 72 hours of submission.
Please fill in all the sections. If not applicable kindly indicate by N/A.
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Chronologically list all work history activities since completion of professional training.

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Please answer all of the following questions. If you answer “yes” to any of the following questions. Please provide details.

File name:

File size:

By submitting this application, I understand and agree as follows:

I attest to the accuracy, currency and completeness of the information provided in this application. I understand and agree that any misstatements in or omissions from the application and attachments thereto may constitute cause for denial of membership.

2. I understand and acknowledge that, as an applicant for membership with MDMEDICINE or designated agent will investigate the information in this application. By submitting this application, I agree to an investigation of any and all statements contained in my application, my Curriculum Vitae. For example, I understand that MDMEDICINE may contact my schools, former and current employers, and organizations which it feels may have information useful in making its membership decision, whether specifically listed on my application or not.

3. I further acknowledge that I have read and understood the foregoing Authorization and Release. A photocopy of this Authorization and Release shall be as effective as the original and authorization constitutes my written authorization and request to communicate any relevant information regarding this application.

4. I authorize any person(s) contacted to provide responsive information to MDMEDICINE. I release from any liability to the fullest extent permitted by law, all persons for their acts performed in a reasonable manner in conjunction with providing information, investigating and evaluating my application and qualifications, and I waive all legal claims against MDMEDICINE and any representative of the organizations contacted or their respective agent(s) who act in good faith and without malice in connection with the investigation of this application.

5. I understand that this is only an application for membership and neither an offer of nor a contract of employment and no part of this application shall be construed as an offer of employment or an employment contract.