Membership Tool Name* First Last Select DegreeSelect DegreeD.O.M.D.OtherOther 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* 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*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 $0.00 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 Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name
