PO Box 27167 | Raleigh, NC 27611
Tel: 919-833-3836 | Fax: 919-833-2023
endocrin@ncmedsoc.org | www.cc-aace.org
Application for Membership
Complete this form or join online at www.cc-aace.org
Section I
Full Name:
Date of Application:
Email:
Practice Name:
Mailing Address:
City:
State:
Business Telephone:
Zip:
Fax:
Section II
Place of Birth:
Date:
Medical School:
Year of Graduation:
Residency Program:
Year of Completion:
Fellowship Program:
Year of Completion:
Are you an AACE member?:
Yes
Is your practice limited to endocrinology?:
No
Yes
No
If no, please specify additional practice area(s):
Are you licensed to practice medicine in North Carolina or South Carolina?:
NC
SC
None
If yes, medical license number:
Section III
APPLICANT
SPONSOR (must be a Society member)
“I hereby apply for membership in the Carolinas Chapter
of Clinical Endocrinologists and attest that the above
information is true and correct.”
“I hereby attest to the qualifications of the candidate
through personal knowledge and recommend the candidate
for membership.”
Signature
Signature
Date
Printed Name
Date
Section IV
2016 Membership Dues: …$100
Check
Card number:
MasterCard
Exp. Date:
Visa
CVV:
Billing Zip:
Complete and return this form by mail or fax to:
CC-AACE, PO Box 27167, Raleigh, NC 27611 | Fax: 919-833-2023
Dues to CC-AACE are not tax deductible as charitable contributions for Federal income tax purposes. However, they
may be deductible under other provisions of the Internal Revenue Code.