Membership Qualification

Members agree to abide by the Code of Medical Ethics and the By-laws of the Society. To assist in upholding these standards, please provide answers to the following questions:

1. Has any action in any jurisdiction, ever been taken regarding your license to practice medicine; actions involving revocation, suspension, limitation, probation or imposed sanctions or conditions?

Yes No

2. Have you ever been the subject of any disciplinary action by any medical society or hospital medical staff?

Yes No

3. Have you ever been convicted of a serious crime?

Yes No

The foregoing statements are true and complete.

If you answered yes to any of these questions, submit full information to contact@JBPI.com
for membership consideration.

Applicant e-mail address as signature:

Date Signed:

Membership Application

Help Us Say Thank You
If you are joining at the suggestion of a current member, we would appreciate the opportunity to say thank you.

Name of Member:

Professional Information

Select One

First Name

Middle Name

Last Name

Qualifications

[Use the CTRL key to select
multiple qualifications]

Credentials

[Use the CTRL key to select
multiple credentials]

Gender

Date of Birth

Professional Title(s)

Office Address

Office Telephone

Office Fax

Hospital / Academic Affiliation

Beginning Year of Medical Practice

Publishing Experience

Number of Books

Number of Papers

National Funding

Funding Organization Name

Personal Information

Spouse First Name

Spouse Last Name

Home Address

Note to Membership Administration

Membership Application Access Code:

Enter The Above Code Here

Thank you for submitting your application. We will contact you as soon as your application is processed.