IMA PA/NP Membership Application

IMA PA/NP Membership Application
Name*

First NameLast Name
Degree*
Date of Birth

MonthDayYear
Date
Gender*

MaleFemale
Spouse Name (If Applicable)
Is Spouse a Physician?

YesNo
Office Information
Name of Employed or Supervising IMA Physician Member *
Practice Office Name*
Practice Office Address*

Street Address

Street Address Line 2

CityState

Zip Code
Applicant's Office E-mail*
Office Manager Name*
Office Manager Email*
Office Phone*

Area CodePhone Number
Office Fax

Area CodePhone Number
Personal Contact Information
By providing your email address you will be automatically subscribed to receive the majority of our communications via e-mail. An email address is required for accessing IMA online services including dues payment, listing updates, or event/workshop registrations. We request personal information to keep you informed of local medical society events you may wish to participate in, knowing your office managers frequently discard bulk mail. The information you provide in the "personal contact information" section will not be released to any person or entity. However, some Ada County Medical Society events require us to share registration information to sponsors for appropriate follow-up under limited circumstances.
Applicant Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Personal Email
example@example.com
Education/Personal Practice Information
ID Medical License Number*
Issue Date*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Primary Specialty
IMA Membership Qualifications
I agree to conduct myself professionally and personally according to the principles of medical ethics of the American Medical Association and the Idaho Medical Association and to be governed by the Constitutions and By-Laws of the Idaho Medical Association my corresponding County Medical Society.
E-Signature Name*
Date*

MonthDayYear
Date
Which email do you prefer IMA sends communications to? (Including IMA newsletters and event info)*

office emailpersonal email
After submitting your application, the IMA will review your application and send an invoice for your IMA and local society dues. This information will also be forwarded onto your local medical society for their own communications with you.
Should be Empty:

IMA PA/NP Membership Application

Education/Personal Practice Information

IMA Membership Qualifications