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Membership Application
Please complete the below fields in their entirety to apply for membership in the Florida Society of Facial Plastic and Reconstructive Surgery . All information submitted is subject to review and verification.
Membership Type:
Member
Associate
Primary Membership:
FSFPRS
FSO-HNS
Secondary Membership:
FSO-HNS
FSFPRS
None
Dues you will owe:
$
395.00
Name on Credit Card:
*
Billing Phone #:
*
After filling in the remaining information on this form you will be redirected to our credit card processing site to pay the membership fees.
* Required Fields
General Information
First Name:
*
MI:
Last Name:
*
Suffix:
Credentials:
*
Date of Birth:
Marital Status:
Single
Married Spouse:
Address (Office):
*
City:
*
State:
*
Zip:
*
Phone:
*
Address (Home):
City:
State:
Zip:
Phone:
Mobile Phone:
Email:
*
Website address:
Academic Education
High School:
Year Graduated:
College:
Year Graduated:
Medical Education
Medical School:
Degree:
Year:
Internship:
Dates of Service:
Residency:
Dates of Service:
Professional Information
Professional Activities since residency
(Account for all time since residency in a choronological sequence)
Military Service:
Dates of Service:
Practice Information
Total years:
Dates:
Location:
Associated with:
Dates:
Location:
Associated with:
Dates:
Location:
Associated with:
Memberships/Affiliations
Medical Society Memberships
County:
State:
Other:
University & Hospital Affiliations
Medical School Teaching Affiliations
Have you ever received an official censure or reprimand from a medical society? If yes, please explain.
No
Yes (explanation below)
Are you now, or have you ever, been party to malpractice litigation? If yes, please explain.
No
Yes (explanation below)
Certified?
Yes
No Eligible:
Florida License Information
Date Issued:
License No.:
Other Degrees or Special Honors Received:
Scientific Articles and Other Publications:
By submitting this application I attest that the foregoing information is true and correct to the best of my knowledge and hereby authorize the
Florida Society of Facial Plastic and Reconstructive Surgery
to obtain educational transcripts and verification of professional activities including associations and employment.
Florida Society of Facial Plastic & Reconstructive Surgery
Terms & Conditions
2400 Ardmore Blvd Suite 302 Pittsburgh, PA 15221 Phone: (412)731-2289 - Fax: (412)243-5160 - Email:
info@FSFPRS.org
