WISCONSIN SOCIETY OF PATHOLOGISTS
2015-2016 MEMBERSHIP APPLICATION/DUES RENEWAL
Membership Year: July 1, 2015 – December 31, 2016
Online dues payments may be made at: www.wispath.com
Name:
Credentials:
Email:
Please indicate your preferred method of contact (check one):
 Work
 Home
Employer:
Address:
City, State, ZIP:
Phone:
Fax:
Complete this section if New Member application (Renewing Members please review and make any changes)
ACADEMIC TRAINING
CERTIFICATION
MEDICAL SCHOOL
SCHOOL
CITY/STATE OR
COUNTRY
START (MO/YR)/ FINISH
(MO/YR)
CLINICAL PATHOLOGY
DATE
PATHOLOGIC ANATOMY
DATE
OTHER
DATE
WI LICENSE #
DEGREE
WI LICENSE # EXP DATE
INTERNSHIP
APPOINTMENTS
HOSPITAL
HOSPITAL
START (MO/YR)/ FINISH
(MO/YR)
DATE
RESIDENCY
HOSPITAL
HOSPITAL
DATE
PHYSICIAN DIRECTOR
START (MO/YR)/ FINISH
(MO/YR)
MEMBERSHIPS
CAP
HOSPITAL
PHYSICIAN DIRECTOR
___________ASCP
WISCONSIN MEDICAL SOCIETY
START (MO/YR)/ FINISH
(MO/YR)
AMERICAN MEDICAL ASSOCIATION
Membership Dues:
Active $175
Graduate of an approved allopathic or osteopathic medical school and board certified in anatomic or clinical pathology by the
American Board of Pathology or the American Osteopathic Board of Pathology. May vote, hold office and serve on committees.
Associate $175
Physician or non-physician scientist in a field allied to Pathology who does not qualify as an Active Member. May be appointed
to committees, but may not vote or hold office.
Resident $50
Graduate of an approved allopathic or osteopathic medical school who is a resident in a training program certified by the Liaison
Committee on Graduate Medical Education. Resident membership automatically terminates the year following training in
Pathology, or after a total of six (6) year of training, whichever occurs first. May vote, hold office and serve on committees.
Retired $30
Total Enclosed: $
Method of Payment:  Check #____________  Credit Card (Visa / MasterCard / Discover)
Card #
Expiration Date
__
Name of Cardholder
Signature
__
Security Code
Please return this form with payment to: Wisconsin Society of Pathologists  563 Carter Court, Suite B  Kimberly, WI 54136
Phone: 920-560-5634  Fax: 920-882-3655  WSP@badgerbay.co  www.wispath.com