South Dakota State Medical Association's Physician members

JOIN OR RENEW

Physician Application

To apply for SDSMA membership, please complete the following form online and send payment to:

SDSMA - PO Box 7406 - Sioux Falls, SD 57117-5406.

Note: All Fields Required

Medical District:

Name:
Address:
City:	State: Zip Code:

Birth date:
License Number:
Date Residency Completed:

Estimate Start Date:
Office Name:
Office Address:
City:	State: Zip Code:
Office Phone:
Office Fax:
Office Email:

Med. School (Full Name)
Date of Graduation
Date State License Issued
Graduate Training (include institutions & specialties)
Specialty
Board Certified	Yes No

Locations you've practiced since medical school:
Have you been convicted, indicted or charged with or is there now pending any criminal prosecution against you which would constitute a felony, involve the practice of medicine or involve moral turpitude?
	Yes No
Have you been subject to proceedings by a licensing agency to deny, cancel, limit, suspend or revoke a medical license?
	Yes No
Have you been subject to disciplinary action by a medical society or hospital medical staff?
	Yes No

Physician References: (For the Seventh District Medical Society and the Black Hills District Medical Society, references must be physicians who are members of the local Society.)
Physician Reference 1 (name and address)
Physician Reference 2 (name and address)

By submitting this form, I hereby declare that my answers and all statements made by me herein are true and correct. Should I furnish any false information in this application, I hereby agree that such act shall constitute cause for the denial of my application for membership or revocation of my membership.