Society for Pediatric Dermatology

SPD Membership Application

To apply for membership:

Complete the form below in its entirety. Print out completed form. Provide signature for Credit Card Information.

Fax to: SPD Headquarters	Fax: (317) 205-9481
Mail to: SPD	The Society for Pediatric Dermatology 8365 Keystone Crossing, Suite 107 Indianapolis, IN 46240
(Credit card or check in US funds drawn on a US bank)

Personal Information:
Date of Application:
First Name:
Last Name:
Date of Birth:
Office Address:
City:
State/Province:
Country:
Zip/Postal Code:
Telephone:
Fax:
E-mail address:
Home Address:
City:
State/Province:
Country:
Zip/Postal Code:
Telephone:
Fax:
E-mail address:
Please indicate your preferred mailing address:		Office Home

Specialty Boards:
Dermatology:
	Eligibility: Certification Year:
Pediatrics:
	Eligibility: Certification Year:
Other: (specify)


Current Hospital Affiliations:
Name of Hospital:	Position:
Name of Hospital:	Position:


Current Medical School Affiliations:
Name of School:	Position:
Name of School:	Position:

PROFESSIONAL REFERENCES (list two SPD Members): (Include letters of proposal from these 2 references with your application. An international applicant needs to include a letter from an accredited dermatologist in their country, a second letter of recommendation from another physician who has worked with them, and the applicant’s CV.)
Name:
Address:
Name:
Address:


Comments:


Applicable Initiation and Membership Fee
	Practicing physician in U.S., Canada and Mexico	$300.00
	Practicing physician in all other countries	$315.00
	Physician in developing countries	$100.00
	Resident in training in the U.S.	$80.00
	Resident in training in Canada or Mexico	$85.00
	Resident in training in all other countries	$100.00
	Resident in U.S. who receives Pediatric Dermatology through a pharmaceutical company	$25.00
	Associate Member	$300.00

All fees are payable in U.S. funds drawn on a U.S. bank. Note: Physicians in developing countries must also have written committee approval. The membership fee covers an initiation fee of $100.00, the first year's dues of $70.00 and the rest is the yearly subscription rate for Pediatric Dermatology, a Blackwell publication. For physicians outside the U.S. the increased fee is to cover the cost for additional postage.


Payment:
Method of Payment:
Cardholder Name:
Card Number:
Expiration Date:
Signature:
Your credit card payment will be processed by the SPD staff upon receiving your application.

Before submitting, make sure all fields are accurate and complete.

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