I declare that should I be elected a member thereof, I agree to hold the Stanislaus Medical Society, its members, examiners, officers and agents free from any damage or complaint by reason of any action they or any of them may take in conjunction with this application.

I agree, in case of the election, that membership shall be conditional upon compliance with the bylaws of the Stanislaus Medical Society, as well as the Constitution and Bylaws of the California Medical Association; I further agree that I will recognize the authorized officer of Stanislaus Medical Society and the California Medical Association as the proper authorities to interpret any doubtful points in professional conduct and will at all times abide by their interpretation; I am aware that information submitted in this application and additional information obtained by the Stanislaus Medical Society will be verified. I hereby authorize other organizations having information relating to this application, including but not limited to hospital medical staffs, other medical societies, medical schools and governmental and regulatory entities, to release any and all such information to the Stanislaus Medical Society.

I declare under penalty of perjury that the above information is true to fact and that if any erroneous statements have been made, such statements shall be considered as just cause for cancellation of my membership in the Stanislaus Medical Society.