Membership Tool Name* First Last Select DegreeSelect DegreeD.O.M.D.OtherOther DegreeApplication Type*New ApplicationMembership RenewalRegistration Type*Active (4 or more years) - $4353rd Year in Practice - $2452nd Year in Practice - $1451st Year in Practice - $50Associate - $55Professional - $435Retired - $44Postgraduate - $25Student - FreeAOA ID NumberIL License Number*IL License Number (Optional)Email* Preferred Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Phone Number*SpecialtyPractice/Employer*Practice/Employer (optional)Hospital or Clinic AffiliationsDo you currently have an unrestricted license to practice medicine?*YesNoHas your license ever been suspended or revoked?*YesNoPlease explain your answer:*Have you ever been convicted of a felony offense?*YesNoPlease explain your answer:*Total $0.00 I would like to pay by:*Online credit cardMailing a check to IOMSTo pay by check, please mail to the following address and indicate clearly on the check what it is for: Illinois Osteopathic Medical Society 4200 Conestoga Dr #150 Springfield, IL 62711Credit Card* DiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name