SOMSA Membership Application

MEMBERSHIP APPLICATION

Please complete this form to apply for membership in the Society of OMS Administrators. You will receive email notification within 24 hours in most cases.

First Name *

Last Name *

Phone 1 *

Direct line when possible.

Job Title *

Gender *

Female

Male

Non-binary

Transgender Female

Transgender Male

Intersex

I prefer not to say

Other

Create an account to save your information and access our online portal!

Password *

Retype Password

How Heard *

Let us know how you found SOMSA.

Referral Source *

If a current SOMSA member referred you, please enter their name so they can be acknowledged!

ABOUT YOUR PRACTICE

We use the information gathered in this section of the website to inform educational programming.

Address Line 1 *

We occasionally send out event flyers and professional development boxes. Be sure to use a current address, whether that is your home or practice location where your home base is.

Address Line 2

State/Province *

Zip/Postal Code *

Ownership Structure *

Number of Offices *

Ambulatory Surgery Center *

Yes

Scope of Services *

Number of Surgeons *

Total number of Full-Time Equivalencies *

Practice Software *

Have an account? Log in

Secure Payment

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.