Application for Membership in the Florida Society of General Surgeons

January 6 2009

Application for Membership in the Florida Society of General Surgeons

Please choose either:
Active Membership ($250.00)
Junior or In Training Membership ($0.00)

Name (First, MI, Last)
Title
Date of Birth
Gender
Social Security
Office Address

City	St Zip
Phone	Fax
Home Address

City	St Zip
Phone	Fax
Send Mail to:
E-mail
Medical School
Year Graduated	Degree
Residency (1)
Dates of Service
List additional residencies if any:
Residency (2)
Dates of Service
Residency (3)
Dates of Service
Certified Am. Bd. of Surg.	Year
Am. Clg. Surg. #	Year

Other Boards: (Please Specify Which and Date)

Hospital Appointments: (Please Specify Which and Date)

Other Society Memberships

County Society Membership
If married, spouse's first name

If you would like to send a CV or similar supporting paperwork, click the Browse button below to attach a file. Most major formats are supported. If you do not see the browse button below, your browser does not support this feature. You can also send a CV here

Active Members must meet the following criteria: degreed MD or DO from an accredited medical school, certified or eligible for certification by the American Board of Surgery, and whose practices are limited to general surgery.

Junior Members must meet the following criteria: degreed MD or DO who is serving in a full-time, board certified training program specific to General Surgery (documentation from chairperson must accompany this application). Within three years of achieving board certification, tis membership shall be converted to an Active status.

I attest that the foregoing information is true and correct to the best of my knowledge and hereby authorize the Florida Society of Ophthalmology to obtain educational transcripts and verification of professional activities including associations and employment.

Method of Payment:

Account Number: Expiration:

Florida Society of General Surgeons
6816 Southpoint Parkway, Suite 1000
Jacksonville, FL 32216
(904) 309-6270
Fax: (904) 998-0855