Personal Information

First Name *

Last Name *

Date of birth *

Email *

Personal email address not practice email

Office Phone Number *

Cell Phone Number *

License Number *

Medical License *

Click to upload

Spouse

Address

Street Address *

City *

State *

Country *

Postal Code *

Primary Specialty *

Secondary Specialty

(optional)

Board Certification *

Click to upload

Board Certification Medical School Attended

Medical School

Medical School City

Medical School State

Other Certification

Click to upload

(optional)

Present Hospital Staff Privileges

Hospital Name

What Type?

Residences, Internships & Fellowships

Residences, Internships & Fellowships Name

Date Residences, Interships & Fellowships

If you are not a member in good standing with ASAPS or ASPS please complete this form.

Disciplinary actions taken against Applicant by hospitals at which Applicant presently has staff privileges (please describe)

Disciplinary action taken against Applicant by other hospital(s) at which Applicant had staff privileges (please describe)

Disciplinary actions taken against Applicant by Composite State Board of Medical Examiners or other licensing body (please describe)

Any drug or alcohol abuse, past or present? (please describe)

The undersigned applicant:

Certify

I hereby certifies that all of the information contained in the application is true and correct; hereby authorizes the Georgia Society of Plastic Surgeons, and its authorized representatives to consult with any and all persons and obtain any and all documents necessary to verify the accuracy of the information contained in this application; hereby releases the Georgia Society of Plastic Surgeons, and its authorized representatives and all persons and organizations who provide information to the Georgia Society of Plastic Surgeons or its authorized representatives in accordance with this application from any liability arising out of the above described authorization actions; hereby agrees to promptly notify the Georgia Society of Plastic Surgeons, in writing, in the event of a material change in any of the information provided by the Applicant in this application.

Applicant Signature

Signature Date

Years in current practice *

Check Out:

First-Year Member Discount

In practice under 2 years?

Enter code: FIRSTYEAR150 in the coupon field for your $150 first-year rate (normally $300). Eligibility verified upon review.

Terms & Conditions *

I agree to the Terms & Condtions

common.challenge.bot_protection_label

Privacy Policy | Terms & Conditions