Fellowship Application for Boston Medical Library

Email*
Name*
First Last
Hospital/Institutional Affiliation*
Departmental affiliation
Work Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone Number*
Preferred Email Address*
Preferred Phone Number*
MD, D.O, D.D.S or D.M.D Degree, School and Year*
Date of Birth*
MM slash DD slash YYYY
Present Academic Affiliation*
Individual Use Agreement*
I acknowledge that access to Library materials is for my individual use only and not for or on behalf of any other person or entity.
Please choose which form of evidence of practice you will provide*
- an M.D or D.O Degree from an American or Canadian Medical School approved by the Liaison Committee on Medical Education and the AMA;
- a DDS from a dental school accredited by the Commission on Dental Education
- a DMD from a dental school accredited by the Commission on Dental Education
- a valid state medical or dental license
- a Massachusetts Medical Society Member card
- Massachusetts Dental Society Membership Card
I acknowledge that my application will not be considered complete until I have attached files containing the evidence of practice indicated in the previous question*
Drop files here or

Max. file size: 300 MB.
Consent*
I agree to the privacy policy.

Payment Method*
Boston Medical Library: Fellowship Dues
Price:
Renews annually on the anniversary of application, billed to the credit card you provide.
Credit Card*
Card Details
Cardholder Name
Automatic Renewal Consent*
I agree that my Fellowship will automatically renew at $100/year at the stated rate, charged to the card provided.
I acknowledge that my application will not be considered complete until I have sent a check of $100 dollars to The Boston Medical Library c/o David M. Pinkham, 475 School Street, Suite 13 Marshfield, MA 02050 **
By checking this box I am submitting my application for fellowship and understand that someone will be in touch with me regarding the necessary documents to continue the application process

Become a BML Fellow