OHOS Physician Membership Application



Physician Name:
Practice Name:
Address:
City:	State: Zip:
Phone:	Fax:
Email Address:
Practice Website:

Please provide the name below of the practice administrator to be added to the OHOS member mailing list:

Practice Administrator:
Phone:	Fax:
Email Address:

Please provide the name below of the staff nurse to be added to the OHOS member mailing list:

Staff Nurse:
Phone:	Fax:
Email Address:

Additional Physicians:

Physician #2:		Email:
Physician #3:		Email:
Physician #4:		Email:
Physician #5:		Email:
Physician #6:		Email:
Physician #7:		Email:
Physician #8:		Email:
Physician #9:		Email:
Physician #10:		Email:

Annual Membership Dues:


PLEASE NOTE:
Full Membership Dues are $300 per physician for the calendar year. Full membership is available to medical, pediatric, gynecologic, radiation or surgical oncologists and hematologists. Full members have the right to attend Board and membership meetings, vote for the election of Board members and officers, serve on committees and hold elective office. They can attend educational meetings and other seminars at discounted or no cost, receive the Society's newsletters, member directory and other publications. Practice managers, nurses and other staff are also included in membership.

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