2010 LOMA MEMBERSHIP APPLICATION

LOUISIANA OSTEOPATHIC MEDICAL ASSOCIATION

Dues Year:  January 1 - December 31, 2010

 

Please complete all information requested in the active fields below, then print the completed form, sign, and mail or fax with check payment or credit card information to the contact information provided at the end of this form.  If preferred you may complete the form and pay by credit card on-line at our secure site as described below.  Thank you very much for supporting LOMA with your membership.  It's your association!  We value your membership and participation.

 

Check Type of Membership:

 

Active DO (In-state Louisiana License):  $200 per year

Retired, Military, Public Health, VA DO (In-state):  $100 per year

 

Out-of-State DO (Licensed in Louisiana):  $100 per year

 

Associate Member (DO w/o LA License, MD, NP, or PA:  $75

 

OMS, Intern, Resident, or Fellow:  $25 per year

 

Contact Information: 

Name Degrees: 

AOA #

Home Address

City/State/Zip Code

Home Phone #      Home Fax #

Mobile #

E-Mail Address

Name of Practice or Employer

Work Address

City/State/Zip Code

Work Phone #                 Work Fax #

Your Preferred Mailing Address for LOMA communications:  Home    Work 

 

Education and Practice Information:

Medical School        Year of Graduation

Specialty 

Secondary specialty, academic or other appointment, title, etc.

Other Certifications

Practice type (group, individual, hospital-based, academic, etc)

Do you accept new patient referrals?

Do you offer OMT? 

Do you accept students for rotations/internships, observation? 

Can you provide CME presentations?    

If so, please briefly list topics

 

LOMA policy is to list ONLY your appropriate business contact information on its web site under membership and physician referral links.  Indicate on the line below if you do NOT want your professional contact information made available on the web site.  Otherwise, you agree to this LOMA policy.  No private information will be listed. 

 

I hereby agree to comply with the by-laws of this association, the Code of Ethics of this profession, and all applicable laws of the State of Louisiana.

 

 

 

__________________________         _________________

Signature                                                                  Date

 

 

 

You can pay by credit card on-line.  If you do, please complete and mail this information form too!  Pay on-line here: Secure Online Dues Payment

 

Or, enclose your check made payable to LOMA with this completed and signed application. 

 

Mail to:

LOMA MEMBERSHIP

c/o Ed Williams, PhD

Executive Director

PO Box 110

Bienville, LA 71008

 For questions or to pay dues over the phone, please call:  (318) 385-7943. You may also Fax your completed form

with attached Credit Card information to (318) 385-7934.   You may also email Ed at: lomadocs@bellsouth.net.