Cleveland Society of Obstetricians & Gynecologists

Excellence in Practice since 1940

Membership Application

DOWNLOAD APPLICATION MEMBERSHIP APPLICATION.DOC

APPLICATION FOR MEMBERSHIP IN

THE CLEVELAND SOCIETY OF OBSTETRICIANS AND GYNECOLOGISTS

NAME:_______________________________________________________________________

OFFICE____________________________   PHONE: ________________Email:___________

ADDRESS:____________________________________________________________________

HOME _____________________________  PHONE: _________________________________

ADDRESS:____________________________________________________________________

BIRTHDATE:   _____________________________  PLACE: ____________________________

EDUCATION:

COLLEGE:      _____________________________   DATES: __________  DEGREE: ________

MEDICAL SCHOOL: _______________________   DATES: __________  DEGREE: ________

SPECIAL/POSTGRADUATE: _________________  DATES: __________  DEGREE: ________

RESIDENCES

HOSPITALS:   ______________________________  DATES:__________  TYPE:____________

                       ______________________________ DATES: __________ TYPE: ___________

OTHER

POSTGRADUATE

STUDIES:       ______________________________   DATES: __________ TYPE: ___________

                        _____________________________  DATES: __________ TYPE: ___________

CURRENT HOSPITAL APPOINTMENTS:___________________________________________

____________________________________________________________________________

TEACHING APPOINTMENTS:___________________________________________________

____________________________________________________________________________

____________________________________________________________

                             (Please enclose a copy of Certificate or other Verification)

FELLOWSHIP OR MEMBERSHIP IN REGIONAL OR NATIONAL MEDICAL SOCIETIES,

COLLEGE AND BOARDS (List latest or most important office or committee assignment)

____________________________________________________________________________

____________________________________________________________________________

APPLICANT'S SIGNATURE:  ____________________________________________________

                                           (Please print name after signature)

MEMBERSHIP STATUS DESIRED:     _______ASSOCIATE________FULL_______AFFILIATE

DATE RECEIVED:________________ ACCEPTED:____________ REJECTED:___________

(revised 5/2012)

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