JPMS Membership Information

New Member Application

Please complete the following information.

JPMS Online Membership Application


PERSONAL INFORMATION




PROFESSIONAL PRACTICE INFORMATION (IF APPLICABLE)




EDUCATIONAL INFORMATION








MEMBERSHIP APPLICATION AND QUALIFICATION QUESTIONS


Members abide by the bylaws of the Jefferson Parish Medical Society. To assist us in upholding these standards, please provide answers to the following questions, sign and date.
If you answer yes to any of these questions, please email full information after submitting your online application.





I am aware that information submitted in this application will be verified. I hereby authorize other organizations having information relating to this application, including governmental and regulatory entities, to release any and all such information. I understand that any false or misleading statement made on my application may be grounds for denial of membership or probation or censure by, or suspension or expulsion from the medical society.
The foregoing information is true and complete.




Membership Type and Dues



TO COMPLETE YOUR APPLICATION, you must click the yellow [Submit Application & Proceed to Payment] button below.

If your membership type requires payment, the next screen will allow you to securely make your payment online with a credit or debit card.

If your membership level does NOT require a payment, then your information will be submitted and no payment information is required.
Total Amount
$
Payment method
Credit/Debit Card
Verification code*