MISSION STATEMENT

To be a networking platform for minority physicians in the Greater New York area, and provide guidance and support as they address their unique challenges and those of their patients - through education, community outreach, political influence, advocacy, and mentorship.

Applicant Information

First name

Last name

Address

City

State

Zip

Email

Office Address

Address

City

State

Zip

Email

Preferred Mailing Address?

Home

Office

Education

Medical School:

Health Professional School:

Degree?

MD

DO

Other

Medical Specialty:

Licensure Number/State

Membership Selection and Dues

Active Physician – $200 licensed physicians (MD/DO), dentists, pharmacists in good standing and licensed to practice in NYS

Affiliate – $150 providers that no longer reside or practice in New York State but wish to remain affiliated with the Society and participate in the activities of the Society

Residents and Fellows – $75 graduates of recognized allopathic or osteopathic medical schools who are in training in accredited postgraduate programs in the tri-State area

Students – $50 enrolled in recognized allopathic or osteopathic medical schools in the State of New York who choose to participate in the activities of the Society

Retired – $100 fully retired from the practice of medicine and will abide by all membership requirements of the Society

Emeritus membership – all past officers who have been in good standing for at least five years and have made significant contributions to the Society

Honorary - Elected by the Society

References

Please list two professional references.

Full Name:

Relationship

Phone

Address

Please list second professional reference.

Full Name:

Relationship

Phone

Address

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to membership, I understand that false or misleading information in my application may result in my dismissal from the society.

Signature

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Date

Month

Day

Year

Click on the file below to download the membership form

Pay by Zelle to

mccunesmithcordice@gmail.com