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Application for Membership in the ji / Ct - County Medical Society Gentlemen:-I hereby make application for membership in your Society, and, if elected, agree to support its constitution and by-laws., 1. I was born at- i'- 7 - 2. My preliminary education was obtained. .-. _- State if common school or collegiate. If the latter, give name of college and date of degree. 3. I graduated in medicine from- ---------- -----/ Give namelof college in full. on the.....- - .-day of. - i--- 4. My State certificate was issued-k4A . _ ------ Give date of State license. 5. I am a member of the following medical societies: --------------------------------------- ----------------------------------------------------------------------- ---- --------------------------------------------------------------------------------------------------------- 6. I have practiced at my present location years, and at the following places for the years named: Name each location and give dates. ------------------------ ------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- ----'--- 7. I now hold, or have held, the following positions: Give places of trust or honor held now --------------------------------------- ----------------------------------------------------------------------- or in the past; prizes received, and dispensary or college appointments. 8. I am examiner for the following Insurance Companies: ---- ---------------------------------------------------------"----------------------- ------ 9. I am .- ..- ..._. . . . - State "general practitioner" or indicate specialty. 10. My office is at . . .]! ------.- ---- ------- . -. ..... ..street; residence -------------------..---------street; telephone number. My office hours are: ... .. j.-f ------ A 1 Respectfully, Name \- ' P. 0.............................................. County ............../t . - - State ............................ ............. NOTE :-The above information is primarily for use in the Card Index System of the County and State, and for the official State and National Directory in contemplation. s W ~ 2
Portrait of Dr. Clara G. Cook, a general practitioner and graduate from the University of Texas, wearing a white blouse. Her name is handwritten on the back of the photo.
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