Membership

FLORIDA OBSTETRIC AND GYNECOLOGIC SOCIETY
Membership Application

Your Information:
First Name:
Last Name:
Title:
Degree:
Email:
Birth Year( YYYY ):
Office Information:
Address:
City:
State: Zip:
County:
Phone:
Fax:
Home Information:
Address:
City:
State: Zip:
County:
Phone:
Fax:
Mail To:
Bill To:

Staff Privileges:

InstitutionCity

Web Community Access:

Desired Username
Password

Education and Training:

Medical SchoolGrad YearDegree

Professional and Postgraduate Training:

Program NameTypeSpecialty

Have your hospital privileges ever been revoked or curtailed?

Practicing at current location since: ( YYYY )

What is your Specialty?

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

Are you a Fellow of the American College of Ob/Gyn?
Effective 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
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PAC Contribution*
Suggested Contribution: $150
Other Amount: $
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Your support of the FOGS PAC is vital to the impact of our legislative efforts.
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