Online Membership Application

When your application is complete click the SUBMIT button to send your application to us. You will receive automatic email notifications updating the status of your application.

A printable application form is also available for those who wish to apply by mail.

Thank you.

Personal Information
Which Membership Category are you applying for?*
Last Name*
First Name*
Middle Initial
Suffix
Degree*
Other Degrees
Birth Date*
MM
DD
YYYY
Photo
Accepted file types: jpg, png, tif, tiff.
A recent photograph is required with your application. You can upload one here, or send one by email or mail later.
Specifications:
• A portrait color photo.
• Jpg or tif format, 300 dpi resolution
Primary Mailing Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
Primary Practice
Type of Practice*
Clinic/Group Name
Secondary Practice
Type of Practice
Clinic/Group Name
Insurance
Insurance Accepted:*
- Medicare
- Medicaid
- Other
Medical Licensing
Washington State Medical License*
Number Date Issued
Other State Licenses
State Number Date Issued
Specialty
Primary Specialty*
Secondary Specialty or Special Interest
Practicing in King County as of*
MM
DD
YYYY
Is this your first year of practice?*
- Yes
- No
Education and Training
Medical School*
Name State Year Graduated
Residency Institution*
State Began Ended
Specialty
State Began Ended
Additional Training
State Began Ended Course of Study
When you submit this form, you will be taken to the Membership Payment page, where you can pay for your membership.

State	Number	Date Issued

Name	State	Year Graduated

State	Began	Ended

State	Began	Ended

Online Membership Application

Personal Information

Primary Practice

Secondary Practice

Insurance

Medical Licensing

Specialty

Education and Training

When you submit this form, you will be taken to the Membership Payment page, where you can pay for your membership.