IOMA Iowa Osteopathic Medical Association

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Thank you for submitting an application for IOMA membership! IOMA staff will be in touch after reviewing your application.

First Name *

Last Name *

Degree *

Sex *

Date of Birth *

Marital Status *

Spouse's Name

Clinic/Office Name *

Office Billing Contact Name

Office Billing Contact Email

Address *

Address 2

City *

State *

Zip Code *

Phone *

Fax

Email *

Home Address

City

State

Zip Code

Has your license to practice medicine ever been denied, suspended, or revoked by any government agency? *

Where do you prefer to receive mail? *

Please explain:

Primary Specialty *

Board Certified *

Date Certified

Name of Board

Are you a fellow? *

Second Specialty

Board Certified

Date Certified

Name of Board

Are you a fellow?

Osteopathic/Medical College graduated from *

Year graduated *

Internship

Year Completed

Residency *

Year Completed *

Years in Practice *

Memberships in Other Professional Associations

AOA

ACOFP

AMA

IMS

PCMS

OTHER

Other Association Membership

Membership Rates *

First Year in Practice $150.00

Second Year in Practice $250.00

Third Year in Practice $375.00

Four or More Years in Practice $495.00

Honorary Member $247.50

Out of State Membership $120.00

Contributions, gifts, or dues paid to IOMA are not deductible as charitable contributions for federal income tax purposes. However, dues and other payments may be deductible by members as a business expense. Please consult your tax advisor.

By submitting this online form, I understand and agree that IOMA will have my contact details for the purpose of processing my information and ensuring full participation.

Payment Information

Amount

Payment Method

PayPal (no PayPal account login required)

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*

Verification code*

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