Application for Membership

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• Thank you for recognizing the importance of supporting your local obstetrics community and applying for membership in the Washington State Obstetrical Association. Your participation and financial support is essential as we continually strive to strengthen our organization.

  Contact Information

• Name
  First Last
• Title
• Address
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• Phone
• Email
• Date of Birth
  MM

  DD

  YYYY

• Education: (School Name/Location and years attended)

• Undergraduate School
• Medical School
• Internship
• Residency
• Other Training

• Professional Information

• Hospital Appointment - Active
• State License #
• Membership in other medical professional societies/associations
• Check all that apply:
  • Practice limited to OB/GYN
  • Diplomate of OB/GYN Boards
  • Family Practicioner
  • AAFP Member
• 
  

  Membership Type

  Please note: WSOA will invoice you for the amount indicated below in the "TOTAL" field

• Membership Dues*
  • Active Physician Member - $150.00
  • Affiliate Midwife Member - $150.00
  • Affiliate/Non-Physician - $150.00
  • Resident - $0.00
  • Fellow - $0.00
• TOTAL
  $0.00
• Credit Card
  American Express

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  MasterCard

  Visa

  Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date   Security Code Cardholder Name
• 
  INQUIRIES Contact the WSOA Office at 206-719-2421 or email admin@wsoaonline.org..