Membership

FLORIDA OBSTETRIC AND GYNECOLOGIC SOCIETY
Membership Application

Your Information:
Full Name:
Title:
Address:
City:
State: Zip:
County:
Phone:
Fax:
Email:

Staff Privileges:

InstitutionCity

Education and Training:

Medical SchoolGrad YearDegree

Professional and Postgraduate Training:

Program NameTypeSpecialty

Have your hospital privileges ever been revoked or curtailed?

Number of Years at Present Location:

Is your practice both Obstetrics and Gynecology?
Gynecology Only?

Are you a diplomate of the American Board of Ob/Gyn?
Efective Date:

Are you a Fellow of the American College of Ob/Gyn?
Efective Date:

Are you a member of the Florida Medical Association?

by checking this box, you indicate that all information provided is complete true to the best of your belief.

Application fee: $50.00
First year Dues: $195.00
Total Charges: $245.00

Card Type: Card Number:
Expiration:

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