Richmond Academy of Medicine

Application for Membership

The greater Richmond area is a great place to practice medicine and receive medical care











RAM ID NUMBER


Full Name:

Practice Name:

Office Address:

City: State: Zip:

Office Phone: Office Fax:

Home Address:

Home Phone: Spouse Name:

Primary Specialty: 2nd Specialty:


CONTACT & SPECIALTY INFORMATION

Gender: Male Female

Date of Birth (mm/dd/yy): ______________

VA Medical License #: _______________

Year License Issued: ________________

MEDICAL EDUCATION

School: ___________________________

Location: __________________________

Degree: __________________________

Year Graduation: ___________________
VERIFICATION

The majority of RAM communications are now conducted through email. Please provide an email address so that you can receive valuable RAM news,
updates, and announcements. Email addresses remain confidential and are never shared with, or sold to, any outside entities.

E-mail Address: ________________________________________ Alternate Email: ______________________________________

Preferred address for: (select one for each item)
Mailing Address: Office address Home address
Email Address: Office email Home email
Phone Number: Office phone Home phone
Your listing in RAMs Online Directory Office address Home address


MEMBER COMMUNICATION PREFERENCES

Return Application to:
Richmond Academy of Medicine
2201 West Broad Street, Suite 205
Richmond, VA 23220
Phone: (804) 643-6631
Fax: (804) 788-9987
Tax Information
RAM dues are 100% deductible
as an ordinary business expense
Please select your membership category below (dues for current calendar year):

Active Member $350 (Pro-rated for current calendar year and due upon approval of application)
(MD or DO licensed to practice in Virginia)

Associate Member (MD or DO not eligible for ACTIVE $350 (Pro-rated for current calendar year and due upon approval of application)
membership; licensed mid-level practitioners, practice executives)

Courtesy Member (Please circle: Intern, resident, or fellow) $ 30 (Full amount due upon approval of application)
Expected Date of Completion: ___________________

Student Member (Medical Student Y1-4) $ 20 (Full amount due upon approval of application)
Expected Date of Completion: ___________________

Non-Resident Member $ 50 (Full amount due upon approval of application)
(MD or DO who resides beyond the Richmond Metro Area)
RAM DUES