South Dakota State Medical Association's Physician members

JOIN OR RENEW

Resident Application

I hereby make application for membership in your Society and, if accepted as a member, I agree to support its Constitution and Bylaws, and to conduct myself professionally and personally according to the principles of medical ethics of the State Medical Association.

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

SDSMA - PO Box 7406 - Sioux Falls, SD 571117-7406.

Click here for dues information.

Note: All Fields Required

Medical District:

Name:
Address:
City:	State: Zip Code:

Office Address:
City:	State: Zip Code:
Office Phone:
Office Fax:

Which address do you prefer for a mailing address:	Home Address Office Address

College / Medical School
School (Full Name):
Degree:
Location:
Date of Graduation:

Residencies
Residency 1:
Name:
Date:
Residency 2:
Name:
Date:

Fellowships
Fellowships 1:
Name:
Date:
Fellowships 2:
Name:
Date:

Licenses
Licenses 1:
State:
Name:
Date:
Licenses 2:
State:
Name:
Date:

Previous Medical / Specialty Society Membership
Membership 1:
Name:
Date:
Membership 2:
Name:
Date:

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

References (list two SD physicians)
Reference 1:
Name:
Address:
City:	State: Zip Code:
Reference 2:
Name:
Address:
City:	State: Zip Code:

I certify that I am a student in good standing at the medical school listed above. 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.