Florida Society of
Physical Medicine and Rehabilitation
 

PO Box 330298
Atlantic Beach, FL  32233-0298
Ph 904 270 8886
Fax 904 246 9233
Email:  Lorry4@earthlink.net, Website:  http://fspmr.org

Venerando I Batas, MD, President, Tampa
Robert B. Dehgan, Vice President, St Augustine
John A Muenz Jr, MD, Secretary, Jacksonville
Duby Avila, Treasurer, Kissimmee

Thank you for your interest in FSPMR. 

Please complete the attached application and return it to Lorry Davis, Executive Director, at the address above.  Make sure you include a copy of your curriculum vitae and a check to FSPMR for $125.00 (application fee and dues for year in which you become a member). 

Provided all is in order, you will be formally considered for membership at our next meeting. 

Benefits of membership include: 

•  meetings with continuing medical education 

•  opportunity for networking in the state  

•  monthly email/fax broadcasts keeping you “in the loop,” and more frequent email/fax broadcasts during Florida’s legislature  

•  a link to organized medicine via representation on the Florida Medical Association’s Specialty Society Section 

If you have any questions, please contact Lorry Davis, Executive Director, contact information above.

FLORIDA SOCIETY OF PHYSICAL MEDICINE AND REHABILITATION 

APPLICATION FOR MEMBERSHIP
(or click here to download application in Acrobat pdf format)

1.      Name_________________________________Email:_______________________________

2.  Office Address________________________________________Telephone______________

_______________________________________________________Fax___________________

3.      Place of Birth______________________________Date of Birth_______________________

Nationality____________________________________                      

4.  Name of Spouse__________________________Children_____________________________

5.      Specialty (1)____________________________(2)__________________________________

6.  Practice:  Private_____________________________________________________________

Medical School Appointment________________________________________________

Hospital(s)_______________________________________________________________

Other___________________________________________________________________

7.       Professional Education

Undergraduate_______________________________________Dates______________________

______________________________________________________________________________

Graduate____________________________________________Dates______________________

______________________________________________________________________________

Postgraduate_________________________________________Dates______________________

______________________________________________________________________________

Other_______________________________________________Dates_____________________

8.      Membership in Professional Organizations, Offices Held, Dates:

Florida Medical Association_______________________________________________________

AAPMR______________________________________________________________________

Other_________________________________________________________________________

9.  Recommended by (must be a current FSPMR member)_______________________________

10.   Florida Medical License #:  ______________________

11.    Signature__________________________________    Date­­­­­­__________________