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Application for Membership in the ..............C ..............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- . ' A ' ... / - -- -- = -- - - - -- - - --4- - - 2. My preliminary education was obtained..- - - :._ State if cominon school or collegiate. < 7- - - -- ---- - -- 4$ ------f------- - - =e If the latter, give name of colle and date of degree. 3. I graduated in medicine from.Z ' Give nam of college in full. on the...A .... day of.... . ..... ..... 1- -/ -- 4. My State certificate was issued-ti_..>4.- A - /- - Give date of Stat license. 5. I am a member of the following medical societies_......................... ,, ----- I A -- - -- - 6. I have practiced _,t my present location .. years, and at the following places for the years named: . J - - - ..f! ThP Name each location and give dates. 7. I now hold, or have held, the following positions -f . Give places of trust or honor held now c - u / or in the past; prizes received, and dispensary or colle appoujtments 4a - .-4 fl ...' R. Tnar.:- "L"X~rf .'ltJ. .Ir$ ari..... r .A 'a! State "general practitioner' or indicate specialty. 10. M y office is at...... / . ..... ... .. ... . .... .street; residence .... . street; telephone number / / My office hours are:...... .. . ...S. .... .....- ....... ..' ....- Respectfully, Name ......... -............- P. o--- ~z ( 6n-r rY < C ounty -....a.. ...<............ . -.. -./ State ..... ... U........................... 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. 3C t q e