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

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*

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

Office Address

Street
Street 2
City
State Indiana Kentucky Ohio Pennsylvania West Virginia
Zip Code
Phone
FAX
Email *
Website (do not include 'http://')

Home Address

Street
Street 2
City
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Zip Code
Phone

Licensure

Education

Post Graduate Medical Training

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 *

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