Printable Application Form

Application for Membership

Genernal Information:
Address:

Office Address

Home Address

Email Address

Specialty Information:
Yes No
If you are NOT a member in good standing with ASAPS or ASPS please complete the Experience Information below.
Experience Information:

Present Hospital Staff Privileges







Residences, Internships & Fellowships:











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The undersigned applicant:

Hereby certifies that all of the information contained in the application is true and correct; hereby authorizes the Georgia Society of Plastic Surgeons, and its authorized representatives to consult with any and all persons and obtain any and all documents necessary to verify the accuracy of the information contained in this application; hereby releases the Georgia Society of Plastic Surgeons, and its authorized representatives and all persons and organizations who provide information to the Georgia Society of Plastic Surgeons or its authorized representatives in accordance with this application from any liability arising out of the above described authorization actions; hereby agrees to promptly notify the Georgia Society of Plastic Surgeons, in writing, in the event of a material change in any of the information provided by the Applicant in this application.

*I understand that by typing my full name and saving this form that I am electronically signing this document and that by doing so, that I acknowledge, agree and attest under penalty of perjury that the information provided on this form is true and correct. I also understand that my electronic signature carries the same legal effect and enforceability as my handwritten signature.