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.

If you have any questions, staff can be reached at:

Iowa Osteopathic Medical Association
6919 Vista Drive
West Des Moines, IA 50266

Phone (515) 282-8192 * Fax (515) 282-9117

To pay by check, download this form to fill out and mail with your check.

First Name *

Last Name *

Degree *

Sex *

Date of Birth *

Spouse's Name

Clinic/Office Name *

Office Billing Contact Name

Office Billing Contact Email

Address *

City *

State *

Zip Code *

Phone *

Email *

Fax

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

Please explain:

Primary Specialty *

Board Certified *

Date Certified

Name of Board

Are you a fellow? *

Second Specialty

Board Certified

Date Certified

Name of Board

Osteopathic/Medical College graduated from

Are you a fellow?

Year graduated

Internship

Year Completed

Residency *

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/Retired $247.50

Out of State Membership $120.00

Osteopathic Student $0

Resident/Fellow $0

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

IOMA has transitioned to our own secure payment gateway. As a result of this change, a 3.25% convenience fee will apply to all credit card payments to help IOMA cover the cost of accepting credit cards. Please let us know if you have any questions. We appreciate your continued support of IOMA.

Amount

$

Payment processing fee

$

Gross Amount

$

Payment Method

Secure Payment Processing

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Holder Name*

Captcha*

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