RMNS Member Application

Name *

First

Last

Email *

Phone

Contact Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Date of Birth

Place of Birth

Country of Birth

Membership Type

Active
Associate
Senior

Clinical Interest and Expertise

Sponsored By

Member Name (2)

Medical School and Year Graduated

Training - Internship and Year Completed

Residency and Year Completed

Fellowship and Year Completed

Current Practice

Have you surrendered or had any disciplinary action taken against a license to practice in a regulated profession?

No
Yes

Have you clinical privileges to practice medicine ever been restricted or revoked?

Yes
No

Has your ability to participate in government funded insurance programs ever been limited or revoked?

Yes
No

Do you currently have a Drug Enforcement Agency (DEA) license in good standing?

Yes
No

Have you pled guilty to, pled no contest to, been convicted of, made a plea in abeyance to, or entered into a deferred sentence with respect to any felony or misdemeanor in any jurisdiction?

No
Yes

Have you been charged with or arrested for any felony or misdemeanor in any jurisdiction?

No
Yes

Are you currently under investigation or is any disciplinary, administrative, or criminal action pending against you now by any agency?

No
Yes