Chapter Membership Application Membership Level change You have selected the Specialty Fellow membership level. The price for membership is $165.00 now. Account Information Already have an account? Log in here Username Password Confirm Password E-mail Address Confirm E-mail Address Full Name LEAVE THIS BLANK Personal Information Your profile information. Doctor Type MD DO OTHER Medical License Number * Medical License State * Medical License Expiration * Date of Birth (MM/DD/YY) * Gender Male Female Fellowship Training if applicable Type of Fellowship * Institution * From (MM/DD/YY) * To (MM/DD/YY) * Board/Professional Certification if applicable Board or Sub-Board * Original Certificate Date * Most recent re-certification date * Board or Sub-Board Original Certificate Date Most recent re-certification date Processing...