Membership Tool "*" indicates required fields Name* First Last Select DegreeSelect DegreeD.O.M.D.Osteopathic Medical StudentOtherOther Degree Application Type* New Application Membership Renewal Registration Type* Active (4 or more years) - $435 3rd Year in Practice - $245 2nd Year in Practice - $145 1st Year in Practice - $50 Associate - $55 Professional - $435 Retired - $44 Postgraduate - $25 Student - Free AOA ID Number IL License Number* IL License Number (Optional) Email (medical students: please use school email address, submission of this form grants permission for IOMS to check student status)* Preferred Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Illinois County:*AdamsAlexanderBondBooneBrownBureauCalhounCarrollCassChampaignChristianClarkClayClintonColesCookCrawfordCumberlandDeKalbDewittDouglasDuPageEdgarEdwardsEffinghamFayetteFordFranklinFultonGallatinGreeneGrundyHamiltonHancockHardinHendersonHenryIroquoisJacksonJasperJeffersonJerseyJo DaviessJohnsonKaneKankakeeKendallKnoxLakeLaSalleLawrenceLeeLivingstonLoganMaconMacoupinMadisonMarionMarshallMasonMassacMcDonoughMcHenryMcLeanMenardMercerMonroeMontgomeryMorganMoultrieOglePeoriaPerryPiattPikePopePulaskiPutnamRandolphRichlandRock IslandSalineSangamonSchuylerScottShelbySt. ClairStarkStephensonTazewellUnionVermilionWabashWarrenWashingtonWayneWhiteWhitesideWillWilliamsonWinnebagoWoodfordIllinois District:*District 1Illinois District:*District 2Illinois District:*District 3Illinois District:*District 4Illinois District:*District 5Preferred Phone Number*Medical School* Medical School Graduation Year or Anticipated Graduation Year* Specialty Practice/Employer* Practice/Employer (optional) Hospital or Clinic Affiliations Do you currently have an unrestricted license to practice medicine?* Yes No Has your license ever been suspended or revoked?* Yes No Please explain your answer:*Have you ever been convicted of a felony offense?* Yes No Please explain your answer:*Total I would like to pay by:* Online credit card Mailing a check to IOMS To 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* DiscoverMasterCardVisaSupported Credit Cards: Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Security Code Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.
