Membership Status Change Request – Montgomery County Medical Society

Membership Status Review Form

If you recently retired or significantly reduced your hours, a membership status change may be appropriate. Please tell us a little more about your recent career change.

Name*
First Last Designation (M.D., D.O., etc.)
Preferred Email*
Preferred Phone*
Which of the following best describes your recent status change?*
- I am retired.
- I have reduced my hours significantly.
If you retired, what was the date of your retirement?
MM slash DD slash YYYY
If you have reduced your hours, how many hours (approximately) are you working per year?
Anything else we should know?