Kentucky Association Medical Staff Services P.O. Box 221445 · Louisville KY 40252-1445 (502) 589-2277 · (502) 562-9584 (fax) Member Application

ACTIVE: Active members shall be those individuals having responsibility in medical staff/healthcare provider credentialing

and/or verification and regulatory compliance activities. Active members shall pay dues and shall be eligible to vote and hold

office. Active members shall be encouraged to join the National Association.

ASSOCIATE: Associate members shall be those individuals interested in the overall goals and objectives of the Association.

Associate members shall pay dues but shall not be eligible to vote or hold office.

DUES: Annual dues for membership classification shall be due and payable January 1 for the ensuing fiscal year. When

membership application with payment of dues is made during the last ninety (90) days of the fiscal year, dues will be considered

paid for the ensuing year. Failure to pay dues by April 31 shall result in termination of membership.

ACTIVE - $35.00 ASSOCIATE - $25.00

Please make check payable to: KENTUCKY MEDICAL ASSOCIATION MEDICAL STAFF SERVICES and return it along with

your completed application to:

Kentucky Association Medical Staff Services

P.O. Box 221445 · Louisville Kentucky 40252-1445

NAME___________________________________________TITLE_________________________________

HOSPITAL/ORGANIZATION_______________________________________________________________

OFFICE ADDRESS ______________________________________________________________________

OFFICE PHONE_____________________________________ FAX_______________________________

HOME ADDRESS _______________________________________________________________________

HOME PHONE _________________________________________________________________________

EMAIL ADDRESS_______________________________________________________________________

I apply for membership in the Kentucky Association Medical Staff Services as follows:

□ Initial Application □Reapplication □Active □Associate

Please indicate which chapter you would like to be affiliated with:

□ State Chapter □ Bluegrass Chapter □ Southern Chapter □ other (specify) _____________________

EDUCATION AND PROFESSIONAL DATA. PLEASE PROVIDE A BRIEF SYNOPSIS OF YOUR JOB

____ Years in present position - Responsible to __________________________

____ Years in hospital/medical field ____ Bed Hospital □Urban □Rural

____ Size of medical staff Departmentalized □Yes □ No

Business Courses (high school) ___________________________________________________________

Adult Education Courses ________________________________________________________________

College Courses or Degree/School _________________________________________________________

Professional Organizations _______________________________________________________________

Speaking Engagements & Teaching Assignments _____________________________________________

________________________________________ ________________

Signature Date

07/98 © 2001 Kentucky Association Medical Staff Services. All rights reserved