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Please complete the following form to apply for membership with the OVSPS. Required fields are marked with *.

General Information

Select membership application status:
Candidate Membership (Not yet board certified)
Active Membership (Board Certified by the ABPS)

First Name *
Middle Initial
Last Name *
Place of Birth
Date of Birth (yyyy-mm-dd format)
Spouse's Name

Please include a recent photo approximately 2 in. x 3 in., in JPEG format (file extension .jpg). Click the browse button below to locate the photo on your computer. When you submit this form the photo will be included in your application.

Are you seeking Emeritus status (retired from practice or age 65 years or older)?
Yes   No

Office Address

Street
Street 2
City
State
Zip Code
Phone
FAX
Email *
Website (do not include 'http://')

Home Address

Street
Street 2
City
State
Zip Code
Phone

Licensure

State Number Date (yyyy-mm-dd)

Education

  Insitution Degree Year
College
College
Medical School
Graduate School
Graduate School

Post Graduate Medical Training

  Position Insitution/City Year
PGY1
PGY2
PGY3
PGY4
PGY5
PGY6
PGY7
PGY8
PGY9
PGY10
PGY11

Professional Activities

Honors, Awards, Research, Grants:

Academic Appointments:

Hospital Affiliations:

Professional Society Memberships:

General Questions

Has membership in any medical society ever been denied, suspended, or revoked?
Yes   No

Have Hospital privileges ever been denied, suspended, or revoked?
Yes   No

Has your license to practice medicine ever been denied, suspended, or revoked?
Yes   No

Are you currently under investigation by the ethics or judiciary committee of any medical Society?
Yes   No

If you answered yes to any of the above questions, please provide additional explanation below.

References

References of two active OVSPS members are required. Please ask each to send a letter of recommendation on your behalf to the Secretary-Treasurer.

Reference 1 *

Reference 2 *

Inorder prevent automated spam bot email submissions, we require that you enter the numeric version of the following textual number:

sixty-eight thousand six hundred and seventy-one

*

 

Ohio,Pennsylvania,West Virginia,Indiana,Kentucky,Pennsylvania American Society of Plastic Surgeons

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