Part-Time Active

PART-TIME ACTIVE MEMBERS practice less than 20 hours per week or have reached the age of 72 and are practicing full or part-time.

Terms:

$175 / Year

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

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City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Full Name:* Full Name is Required

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Company / Practice:* Company / Practice is Required

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Medical Speciality:* Medical Speciality is Required

Board Certification: Board Certification is not valid

Board Certification Date: Board Certification Date is not valid

Missouri License:* Missouri License is Required

Office Address:* Office Address is Required

Office City:* Office City is Required

Office State:* Office State is Required

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Have you, or any license or right to practice held by you, been restricted or disciplined, such disciplinary action to include, but not be limited to, revocation, suspension, probation, censure, or reprimand, whether voluntarily agreed to or not, by any U.S. state, territory, federal agency, Canadian province, or foreign country?: Have you, or any license or right to practice held by you, been restricted or disciplined, such disciplinary action to include, but not be limited to, revocation, suspension, probation, censure, or reprimand, whether voluntarily agreed to or not, by any U.S. state, territory, federal agency, Canadian province, or foreign country? is not valid

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Check Payment

Please mail your check to:
Greene County Medical Society
1911 S National Ave, Ste 401
Springfield MO 65804-2213
Phone 417-887-1017
Fax 417-719-9016

Direct Bill Cox

Direct bill to Cox. **Cox Resident Associates Only**

GCMS ONLY

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