Kentucky Medical Association

<% ' *** Insert Record: construct a sql insert statement and execute it MM_editAction = CStr(Request("URL")) If (Request.QueryString <> "") Then MM_editAction = MM_editAction & "?" & Request.QueryString End If If (CStr(Request("MM_insert")) <> "") Then MM_tableName = "KMA_Members" MM_redirectPage = "membershipform.asp" ' create the insert sql statement MM_tableValues = "" MM_dbValues = "" MM_fieldsArray = Split(MM_fields, ",") For i = LBound(MM_fieldsArray) To UBound(MM_fieldsArray) Step 5 FormVal = CStr(Request.Form(MM_fieldsArray(i))) Delim = MM_fieldsArray(i+2) If (Delim = "none") Then Delim = "" AltVal = MM_fieldsArray(i+3) If (AltVal = "none") Then AltVal = "" EmptyVal = MM_fieldsArray(i+4) If (EmptyVal = "none") Then EmptyVal = "" If (FormVal = "") Then FormVal = EmptyVal Else If (AltVal <> "") Then FormVal = AltVal ElseIf (Delim = "'") Then ' escape quotes FormVal = "'" & Replace(FormVal,"'","''") & "'" Else FormVal = Delim + FormVal + Delim End If End If If (i <> LBound(MM_fieldsArray)) Then MM_tableValues = MM_tableValues & "," MM_dbValues = MM_dbValues & "," End if MM_tableValues = MM_tableValues & MM_fieldsArray(i+1) MM_dbValues = MM_dbValues & FormVal Next MM_insertStr = "insert into " & MM_tableName & " (" & MM_tableValues & ") values (" & MM_dbValues & ")" ' finish the sql and execute it Set MM_insertCmd = Server.CreateObject("ADODB.Command") MM_insertCmd.ActiveConnection = "dsn=membershipform;" MM_insertCmd.CommandText = MM_insertStr MM_insertCmd.Execute ' redirect with URL parameters If (MM_redirectPage = "") Then MM_redirectPage = CStr(Request("URL")) End If If (InStr(1, MM_redirectPage, "?", vbTextCompare) = 0 And (Request.QueryString <> "")) Then MM_redirectPage = MM_redirectPage & "?" & Request.QueryString End If Call Response.Redirect(MM_redirectPage) End If %> Kentucky Medical Association

How to Join

Membership in the KMA is contingent upon a physician being accepted as a member of the county medical society. The information submitted here will be sent to the county medical society where you practice (and/or reside). Upon approval by the county society, a Dues Statement will be forwarded. If you have any questions, please contact Kellie Bennett.

I hereby make application for membership in the Kentucky Medical Association and the County Medical Society.

To join KMA through the Greater Louisville Medical Society, click here.
To join KMA through the Lexington Medical Society, click here.

KMA Membership Form

First Name/Middle Initial:
Last Name:
Suffix
Degree: MD DO	Gender: Male Female
Birth Date	mm/dd/yyyy
Spouse Name
Practice Information
KY License	Year Licensed
Primary Specialty
Secondary Specialty
Office Information
Practice Name
Address
Address
City
State
Zip Code
Phone
Fax
Home Information
Address
City
State
Zip Code
Phone
E-mail:
For Mailing, please use:	Office Address Home Address
Email Subscriptions:	Communicator Legislative Bulletin
Medical Education
Medical School
Location
Degree	Year yyyy
Residencies/Fellowships
Year Completed	Location
Year Completed	Location
Year Completed	Location
Board Certified By	Year Certified

Active Hospital Affiliations:
Professional Association Memberships:

If elected to membership, I agree to conduct myself professionally and personally according to the principles of medical ethics and to be governed by the Constitution and By-Laws of the County Society, Kentucky Medical Association and the American Medical Association.

I hereby release, and hold harmless from any liability or loss, the County Medical Society, and the Kentucky Medical Association, their officers, agents, employees, and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and hereby release from any liability any and all individuals and organizations, who in good faith and without malice, provide information to the above named organizations, or to their authorized representatives, concerning my professional competence, ethical conduct, character and other qualifications for membership.