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Application for Membership

Please fill out an APPLICATION FORM and save in Microsoft Word format.

Applications may be submitted via e-mail to apply@clevederm.org

To submit an application via e-mail, please attach the following documents:

1. Filled out APPLICATION FORM

2. Photo in JPG, JPEG or GIF format (<500kb in file size)

3. Curriculum Vitae (Resumé) in Microsoft word or PDF format

4. Copy of your State Medical License  in JPG, JPEG, or GIF format (<500kb in file size)

5. Copy of your Board Certification  in JPG, JPEG, or GIF format (<500kb in file size)

6. Copy of your ECFMG Certificate, if applicable, in JPG, JPEG, or GIF format (<500kb in size)

7. Any additional attachments, such as letters of recommendation (if possible).

***CLICK HERE TO DOWNLOAD THE APPLICATION FORM***
 

To submit an application via postal mail, please send paper copies of the documents listed above to:

Dr. Terri Sivik,
6701 Rockside Rd., Suite 330,
Independence, Ohio 44131