NSDDS Membership Application

NSDDS New Member Application

Please complete the below application to become a member of the NSDDS.
Download Membership Category Information.
Applicant Name*

First NameLast NameMD, DO, PA, Nurse, Etc
Practice/Institution Name*
Practice Type*

SoloGroup, Single SpecialtyGroup, Multi-SpecialtyAcademic
Practice Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preffered Address (if different from above. This will be included in your membership record, not on the website)

Street Address

Street Address Line 2

CityState

Zip Code
Email Address*
This email will be used for NSDDS correspondence
Practice Phone Number*
Practice Website
I consent to having my full name, practice address, practice phone number and practive website displayed on the NSDDS Website.*

YesNo
If Resident or Medical Student, what is your program month and year of completion?
If Fellow or Associate, what is your certification?

American Board of DermatologyRoyal College of PhysiciansAmerican Osteopathic Board of Dermatology
If Fellow or Associate, what year did you receive the above certification?
If you are a registered nurse, nurse practitioner, licensed practice nurse or a physician assistant, a letter from your supervising dermatology physician is required. If you are Resident or Medical student, a letter from your program is required.

Cancelof
If Registered Nurse, Nurse Practitioner or Licensed Practice Nurse, add License # and State:
If Physician Assistant, please add PA Program Attended and Graduation Date
If applying for Adjunct Membership, what industry company do you work for?
Adjunct members are Medical Science Liaison working for industry
I represent that the information provided in this application is truthful and accurate. I understand that the NSDDS will reach out for additional information as needed to process my membership application.
Signature*

Clear

Dues Payment

Fellow

$250.00

Associate

$200.00

Clinical Staff

$200.00

Resident

$ Free

Medical Student

$ Free

AdjunctMedical Science Liaison working for industry

$300.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

NSDDS New Member Application