Taking on Tobacco - Info for Practitioners

Info for Practitioners

San Diego Pulmonary Society Membership Registration

ACTIVE MEMBERSHIP REQUIREMENT: Active members shall have an MD, PhD or equivalent degree. They may be specialists in respiratory disease, or other physicians and scientists interested in the objectives of the Society. Active members shall have the privilege of voting and holding office. Dues are $50.00 per year and payable to San Diego. Pulmonary Society. (Please complete and either submit with your credit card payment, or print out and mail with a check.)

You may download a printable form in PDF format, or complete the form below.
(Note: To view Adobe Acrobat files. You will need the Adobe Acrobat Reader.)

Personal Information
Name:
Middle:
Last:
Date of Birth:	//
Address:
City:
State:
Zip:
Phone:
Fax:
Email:

Affiliation Information
Hospital or Institutional Affiliation (if not listed above)

Member of the American Thoracic Society	Yes:	No:
Member of the California Thoracic Society	Yes:	No:

Education Information
MD	PhD	Other
Specialization:
School:
Year:

Specialization: Please indicate your current primary and secondary specialties by checking one box in each column.
	Primary	Secondary
Administrative Medicine
Allergy
Anesthesiology
Cardiovascular Disease
Family Practice
General Practice
Internal Medicine
Pathology
Pediatrics
Public Health
Pulmonary Disease
Radiology
Thoracic Surgery

Scientific Interest: Please indicate your primary and secondary interests within the field of respiratory disease by checking one box in each column.
	Primary	Secondary
Bacteriology
Biochemistry
Cardiopulmonary Physiology
Clinical Medicine
Environmental Medicine
Epidemiology
Immunology
Inhalation Therapy
Institutional Teaching
Pulmonary Nursing
Rehabilitation
Virology

Status:
Administrative
Fellow
Industrial Medicine
Institutional or Military
Medical School Faculty
Private Practice
Research
Retired
Other

Credit Information
For Credit Card Payment, please complete the following: Total $50.00
Charge Payment to:	MasterCard	Visa	American Express
Card Number:		Expiration Date:
By clicking the submit button below you agree that all the above information is complete and accurate and you agree to the terms of payment