Chicago MOLA

Membership Application

Thank you for your interest in becoming a member! Please complete the application questions below.

Step 1 of 5 Contact / Contacto
Contact
Location
Professional
Profile
Pay

Contact information

Chapter and how we can reach you.

Location & background

Address and nationality.

Professional information

Specialty, interests and credentials.

If you are a student, please indicate specialty(ies) of interest, which will facilitate matching you with attendings in those fields. If you are a non-physician professional, please choose "Not Applicable" and specify your area of ​​specialty or profesión”: / Si es un estudiante por favor indique la(s) especialidad(es) de interés, lo que facilitará encontrar asistentes en esos campos. Si no es un profesional medico seleccione “No aplicable” y especifique si área de especialidad o profesión”:
Please choose your interests / Por favor elija sus áreas de interés:







Please select your expected graduation year / month (Membership valid until the year of graduation) / Escoja el año/mes esperado de graduación (Membrecía valida solo hasta el año de graduación)

What year did you graduate from your highest degree? / ¿En qué año se graduó de su título más reciente?

















Profile & social

Optional — helps us recognize you in the community.

MOLA frequently likes to recognize and engage with members through our social media platforms when they participate in activities and events. / MOLA con frecuencia le gusta reconocer e interactuar con sus miembros a través de nuestras plataformas de redes sociales cuando participan en actividades y eventos.

Please share any social media handles you wish to use professionally and share with MOLA: / Por favor comparta cualquier red social que desee utilizar profesionalmente y compartirla con MOLA:
We at MOLA love to brag about our members! If you would like to be featured on our social media platforms and promotional materials, please include your headshot and a 2-3 sentence bio (Optional): / ¡En MOLA nos encanta dar a conocer sobre nuestros miembros! Si desea aparecer en nuestras plataformas de redes sociales y materiales promocionales, por favor incluya una foto suya de su rostro y una biografía de 2-3 oraciones (Opcional):

Membership & payment

Select your plan and review the total charge.

Membership type / Tipo de membresía

Membership dues / Cuotas de membresía

Physician / Médico

e.g., MD, DO, MD PhD

Resident – 60% discount / Residente

Student – 100% discount / Estudiante *

Health professional (non-physician)

e.g., PA, RN, APN, Medical Administrator

International graduate (IMG) / Graduado internacional

* Minimum volunteer commitment of 5 hr / 2 events per year. Student membership valid until graduation year.

Join MOLA Members Community / Comunidad de miembros

MOLA community enhances member growth through collaboration and virtual networking.

If you uncheck this box, you can request registration later at [email protected]

Payment summary / Resumen de pago

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Apply coupon / Aplicar cupón
$

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