Membership Application ⇽ Medical Student Member | King County Medical Society on Glue Up

Glue Up account creation information.

Please enter a first name

First Name *

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Please enter a last name

Last Name *

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Please enter a valid email address
e.g. john.doe@glueup.com

Email Address *

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・8 characters minimum
・one upper case letter
・one lower case letter
・one number
・one special character (@$!%*?&)

Password *

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・8 characters minimum
・one upper case letter
・one lower case letter
・one number
・one special character (@$!%*?&)

Confirm password (at least 8 characters) *

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Please fill in your member application details.

Please enter a first name

First Name *

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Please enter a last name

Last Name *

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Please enter a valid email address
e.g. john.doe@glueup.com

Email *

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Please select an option

Which Membership Category are you applying for? *

Degree (MD/DO)

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Please enter a valid date
e.g. mm/dd/yyyy, dd-mm-yyyy or yyyy-mm-dd

Date of Birth

Please enter a address

Address *

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Address City

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Address State

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Address Type

Address Zip Code

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Country/Region

Sex

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Phone

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P or N (From access)

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Primary Practice

Type of practice

Clinic/Group Name

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Insurance

Medical Licensing

Washington State Medical License Number

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Please enter a valid date
e.g. mm/dd/yyyy, dd-mm-yyyy or yyyy-mm-dd

Date issued

Other State Licenses

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e.g. mm/dd/yyyy, dd-mm-yyyy or yyyy-mm-dd

Date issued

Specialty

Primary Specialty

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Secondary Specialty or Special Interest

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Please enter a valid date
e.g. mm/dd/yyyy, dd-mm-yyyy or yyyy-mm-dd

Practicing in King County as of

Is this your first year of practice?

Education and Training

Medical School (Name, State, Year Graduated)

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Residency Institution (State, Started, Ended)

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Membership Status

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Glue Up account creation information.

Please fill in your member application details.

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