Become a Member of KOMA

We invite you to become a member of the Kentucky Osteopathic Medicine Association. Join below or download the pdf form and fax or mail it to us today!


KOMA Membership Application Enter your information below. All fields marked with an asterisk (*) are required.
Contact Information
Prefix
First Name*	A value is required.
Middle Name/Initial
Last Name*	A value is required.
Suffix
Company/Institution*	A value is required.
Address*	A value is required.

City*	A value is required.
State*
Zipcode*
County in KY*	A value is required.
Telephone*	A value is required.
Fax
Email Address*	Invalid format.
Practice Type*	Please select a valid item.Please select an item.
I am willing to be a contact for shadowing.	Please select an item.
Membership Fees+
Please select the appropriate Membership Level:
Membership Level	Please select an item.
+A percentage of dues payments are deductible by members as an ordinary and necessary business expense. The organization estimates 2% of your annual membership dues is spent on lobbying expense and therefore nondeductible as a business expense. Please consult your tax professional for further information.
Contribution	Please consider a contribution to the the Student Presentation Fund. Just $50 covers one Student.
Payment
Credit Card Type*	Please select an item.
Name On Card*	A value is required.
Card Number*	A value is required.
Expiration Date*	Please select an item. / Please select an item.
CVV*	A value is required.What's This?

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Kentucky Osteopathic Medical Association
2424 American Lane
Madison, WI 53704

Phone: 608.441.1060
Fax: 608.443.2474
info@koma.org

Kentucky Osteopathic Medical association

Become a Member of KOMA

KOMA Membership Application

Contact Information

Membership Fees+

Payment