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Please complete the following form to apply for membership with the OVSPS. Required fields are marked with *.
Select membership application status:
Candidate Membership (Not yet board certified)
Active Membership (Board Certified by the ABPS)
Place of Birth
Date of Birth
Please include a recent photo approximately 2½ in. x 3½ 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)?
Select a state
(do not include 'http://')
Select a state
District Of Columbia
Honors, Awards, Research, Grants:
Professional Society Memberships:
Has membership in any medical society ever been denied, suspended, or revoked?
Have Hospital privileges ever been denied, suspended, or revoked?
Has your license to practice medicine ever been denied, suspended, or revoked?
Are you currently under investigation by the ethics or judiciary committee of any medical Society?
If you answered yes to any of the above questions, please provide additional
References of two active OVSPS members are required.
Please ask each to send a letter of recommendation on your behalf to the Secretary-Treasurer.
Inorder prevent automated spam bot email submissions, we require that you enter the numeric version of the following textual number:
eleven thousand seven hundred and thirty-four
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