Join Now
 
Membership Application  
I hereby submit my application for membership in your Society. I understand that dues will be billed upon approval of my application. Also, submitted below are my professional qualifications and attached are my two letters of recommendation.
 
Membership Type: Member
Associate
Primary Membership:
Secondary Membership:
Dues you will owe: $395.00
 
General Information
First Name:   MI: 
Last Name:
Suffix:
Credentials:
 
Date of Birth:
 
Marital Status: Single   Married   Spouse: 
 
Address (Office):
City:    State:     Zip: 
Phone:
 
Address (Home):
City:    State:     Zip: 
Phone:
 
Mobile Phone:
Email:
Website address:
Academic Education
High School:    Year Graduated: 
College:    Year Graduated: 
Medical Education
Medical School:    Degree:        Year: 
Internship:    Dates of Service: 
Residency:    Dates of Service: 
Professional Information
Professional Activities since residency (Account for all time since residency in a choronological sequence)
 
 
Military Service:    Dates of Service: 
Otolaryngology Practice Information
Total years:
Dates:
Location:
Associated with:
 
Dates:
Location:
Associated with:
 
Dates:
Location:
Associated with:
Memberships/Affiliations
 
Medical Society Memberships
County:
State:
Other:
 
University & Hospital Affiliations
 
 
Medical School Teaching Affiliations
 
Have you ever received an official censure or reprimand from a medical society? If yes, please explain.
  No
Yes (explanation below)
 
Are you now, or have you ever, been party to malpractice litigation? If yes, please explain.
  No
Yes (explanation below)
 
Certified by American Board of Otolaryngology?
  Yes
No   Eligible: 
Florida License Information
Date Issued:
License No.:
Other Degrees or Special Honors Received:
 
Scientific Articles and Other Publications:
 
By submitting this application I attest that the foregoing information is true and correct to the best of my knowledge and hereby authorize the Florida Society of Otolaryngology-Head & Neck Surgery to obtain educational transcripts and verification of professional activities including associations and employment.
For security purposes, please type the letters/numbers that you see in the image into the box below.

 

 
Florida Society of Otolaryngology - Head & Neck Surgery  About FSOHNS | Terms & Conditions | Member Login