Apply for membership

Download the form below or fill out the application online.  Click here to pay dues online.

Application for Membership
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  4. (valid email required)
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  6. Medical Training and Education
  7. Residency/Fellowship - Hospital/Institutions
  8. Medical Licensure
  9. Has your license to practice in any jurisdiction ever been denied, restricted, limited, suspended or revoked; have you ever been reprimanded by a licensing agency; or have you ever surrendered your license?
  10. I hereby certify that I am a legally registered physician, residing or practicing in Stark County in the state of Ohio and that I have not been convicted of a felony. If accepted as a member, I agree to abide by the Constitution and Bylaws of the SCMS and the OSMA, and the Principles of Medical Ethics of the American Medical Association.
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