Category of Membership: ASSOCIATE MEMBER
APPLICANT INFORMATION
* = REQUIRED FIELDS. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED
MEMBERSHIP CATEGORY:
ASSOCIATE MEMBER:
Any physician in good standing who is a resident of the United States of America or Canada shall be eligible to become an Associate Member if one or more of the following criteria have been met: (1) three years of full time experience in the practice of dermatology; (2) recognized teacher of dermatology; or (3) training which qualifies the individual for teaching credentials; or (4) requirements met from the examination in dermatology of the American Board of Dermatology or the Royal College of Physicians and Surgeons in Canada.
Membership Dues for Associate Member = $125

APPLICATION DATE: *

Name: *
First * Middle Last *
Degree or Title: *
Date of Birth: *  *  *  * 
Spouse’s Full Name:

WORK MAILING ADDRESS:
Company (If Applicable):  
Address 1: *    
Address 2:  
City: *  
State: *  
Zip: *  
Country: *  
(If Other):

If you reside in a European country, you may apply for
Joint WDS-Eu/WDS membership. Click here to apply.
Phone: *  
City/Area Code *   Local Number *   Country Code *  
Fax Number:  
City/Area Code *   Local Number *   Country Code *  
eMail: *  
Citizenship: *  
Practice: *  
(If Other):
Preferred Mailing Address:
HOME MAILING ADDRESS:
Address 1: *    
Address 2:  
City: *  
State: *  
Zip: *  
Country: *  
(If Other):

If you reside in a European country, you may apply for
Joint WDS-Eu/WDS membership. Click here to apply.
Phone: *  
City/Area Code *   Local Number *   Country Code *  

PRIVACY POLICY:
  -  You may publish my contact information on the WDS website to be viewed by members only *  
  -  Do NOT publish my eMail address at all in print or on the WDS website *  
  -  Do NOT publish my contact information in print or on the WDS website *  

WDS FIND A DERMATOLOGIST:
  -  Please add my information to the Find a WDS Dermatologist online search directory *  
SPECIAL NOTE: The WDS Find a Dermatologist feature is an online search application that allows visitors to locate you as a dermatologist in their area. Listing your  practice in the directory provides an easy way to share your credentials, potentially acquire new patients and  demonstrate your affiliation with a respected organization such as the WDS. Visitors will see your name, member category, office, address, city, state, zip and phone.

EDUCATION INFORMATION
Undergraduate Institution:
Institution: *  
Degree: *      Year Completed: *  
Medical or Graduate School:
Institution: *  
Degree: *      Year Completed: *  
  *  
Institution: *  
Year Completed/Proposed Completion: *   
Institution: 
Year Completed/Proposed Completion:   
Institution:
Position Or Title (If Applicable):   

CERTIFICATION
American Board Of Dermatology:
Dermatology Board Eligibility Year
 Dermatology Board Certification Year

Royal College Of Physicians And Surgeons Of Canada:
Dermatology Board Eligibility Year
 Dermatology Board Certification Year

Equivalent Board (Other Countries):
          Board:      Country:           
Dermatology Board Eligibility Year
 Dermatology Board Certification Year

ADDITIONAL INFORMATION

Has your license to practice medicine in any jurisdiction ever been limited, suspended, or revoked *

Have your privileges at any hospital ever been suspended, diminished, revoked or not renewed? *

Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any local, state, or national medical society? *
Are there any charges pending resolution by a Board of Medical Examiners in any state in which you have practiced medicine? *

Have you ever been sanctioned by the Board of Medical Examiners? *

SPONSORS
List names of two members of the Women’s Dermatologic Society from whom the Membership Committee may request letters of endorsement. One of these members should reside in the vicinity of the applicant. (Contact WDS headquarters if sponsors are needed.)

     WDS MEMBER SPONSOR #1:   *

     WDS MEMBER SPONSOR #2:   *

APPLICATION & DUES INFORMATION
INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.
Application must be accompanied by first year’s annual dues. (Dues will be refunded if membership is not granted).

MEMBERSHIP COSTS:

  • US $125 for the annual dues
  • IF YOU DO NOT INCLUDE FIRST YEAR DUES YOUR APPLICATION WILL NOT BE ACCEPTED.

METHOD OF PAYMENT:

  • Visa
  • MasterCard
  • American Express

    Click the 'SUBMIT and PROCEED' button below and you will be taken to step 2 in the application process

PAYMENT OPTIONS:

       1 Year Membership - US $125.00
       3 Year Membership (discount) - US $350.00
       3 Year Membership (discount) - US $375.00 (US $350 dues + $25 Legacy Contribution)


REFERRAL CODE:


Additional Comments:






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*Note: Use of the name of Women's Dermatologic Society
and/or the Society logo on business or in any advertisement is prohibited.
**Membership applications are reviewed and approved by the Board of Directors twice yearly.