Step 1.

Complete Your Application

Please complete all required information as shown below.  If you have any questions, feel free to contact our executive office at (937) 223-0990.

Purchasing for Someone Else?

If you’re looking to purchase Membership on behalf of another individual who will actually be the member, please select the number of memberships you wish to purchase below and proceed:

Physician Details

Please provide information as it pertains to you as a physician.

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Home Address & Phone

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Personal Details

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Professional Information

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Account Details

Please note that your license number will serve as your login. If you are currently a student or resident and do not yet have your license number, please substitute your email address with this field.

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Practice Details

Please provide information about the practice you are affiliated with.

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