First Name * Middle Name Last Name * Gender * Date of Birth * Address Line 1 * Line 2 City * State * Zip Code * Phone Number * Fax Number * Email Address * Status Status Options * - Select -StudentResidentMDDO MD License # * DO License # * Specialty Please use this area to provide any additional information. 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 Constitutions and By-Laws of the Maine Medical Association. I hereby release, and hold harmless for any liability or loss, the Maine Medical Association, the 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. CAPTCHAThis question is for testing whether or not you are a human visitor and to prevent automated spam submissions.