Interest Groups  »  WDS Young Physicians Interest Group  »  Young Physicians Interest Group Participation Application

WDS Young Physicians Interest Group Participation Application

1. APPLICANT INFORMATION

Date: (required)
Name: (required)
Address:
City:
State:
Zip:
Telephone: (required)
Fax:
E-Mail Address: (required)

2. INTEREST GROUP INFORMATION
Areas of Interest: (Check all that apply)
   Starting a new practice
   Expanding an existing practice
   Managing an existing practice
   Serving on the WDS Young Physicians Interest Group task force
   Providing Young Physicians Interest Group content (e.g. Podcasts, Facebook contributor, etc.)
   Host a WDS Young Physicians Interest Group networking event
   Host a private practice visit

WDS Young Physicians Interest Group ListServe: (required)
Would you like to subscribe to the ListServe provided exclusively to WDS Young Physicians Interest Group members?
   Yes (Note: your eMail address listed above will be used for your ListServe member account)
   No

Would you consider volunteering as a moderator for the WDS Young Physicians Interest Group ListServe?
   Yes
   No

Confidentiality: (required)
Would you like your information to be made available in a Young Physicians Interest Group section on the WDS website?
   Yes, allowing the email address on the website for Members-Only (public will not have access to eMail)
   Yes, but do not provide e-mail address
   No

Would you allow the printing of your Young Physicians Interest Group participation information in the printed WDS Directory for members?
   Yes, including my email address
   Yes, without my email address
   No, to any information being placed in the printed membership directory

3. ADDITIONAL COMMENTS & INSTRUCTIONS


PLEASE NOTE: You will receive eMail confirmation of your application