DIRECTORY APPLICATION: BEST BOARD CERTIFIED PLASTIC SURGEONS

Attention Board-Certified* Plastic Surgeon Applicants:

Please note that the Directory Listing Information has changed.
Plastic Surgeons in our City Directories will have MORE information offered to the public.
Please be sure to carefully READ, SIGN and DATE the application before mailing!
We do not accept all plastic surgeons - you MUST qualify!
EASY PRINT OUT DIRECTORY APPLICATION - 2 pages

BoardCertifiedPlasticSurgeon.com
Directory Application - MUST be acompanied by a signed and dated DIRECTORY PLEDGE (page 2)
Page 1 of 2
Current Fee: $75.00 for 6 Months/ $125.00 Year per surgeon & city

*Fee is for 12 months.
Payment to BoardCertifiedPlasticSurgeon.com by check, cashier's check or money order only!

Plastic Surgeon's name (as it appears on medical license):

Gender: Male or Female (circle)

State and MD Licence #:

List past and/or present licensure in other states or countries:

Name as it should appear on listing:

Practice name (if different than above):

Practice street address:

Practice City/Town/Zip Code:

*Listing city:
* Some surgeons request to be listed in a city other than their actual practice city. This request may be granted, at out sole discretion, IF the city you request is within 10 miles of your actual practice office.

Specialty (check one or both): Cosmetic______ Reconstructive_______

Option: List up to 4 procedures (frequently performed by you) in each category:

COSMETIC PROCEDURES:

RECONSTRUCTIVE:

List Office Hours (if desired):

Contact person: _______________________E-Mail:_____________________________________ Publish?______

Office Telephone:___________________________ Fax#_______________________________Publish Fax?_____

Your current web site address: http://www.____________________________________
Web address will be listed but NOT be linked.
We currently link only SPONSORS to their personal practice sites.

Month/Year Board Certified by American Board of Plastic Surgery or RCPSC:

Please mail completed, signed application and $125.00 fee (payable to BoardCertifiedPlasticSurgeon.com) to:
BoardCertifiedPlasticSurgeon.com, PO BOX 442, Pittston, PA 18640.

Terms

The terms of this agreement are for a limited time. The administrators of www.BoardCertifiedPlasticSurgeon.com reserve the right to change any and all terms and agreements without prior notice, and at our sole discretion. We also reserve the right to refuse to list any applicant, or to remove a listing, subject to a refund as set forth above, for any reason at any time, at our sole discretion. Please note that our administrators may check with applicable state Board of Medical Examiners/Board of Medicine to verify certain credentials. Thank you.
Copyright 2008 - 2009 by BoardCertifiedPlasticSurgeon.com (sm) All Rights Reserved

END of PAGE ONE

BoardCertifiedPlasticSurgeon.com
Directory Application
Page 2 of 2 - Must be accompanied by Page 1 (Information Page)
Current Fee: $125.00 per surgeon & per city each ($75.00 6 month optional).

*Fee is for 12 months.
Payment to BoardCertifiedPlasticSurgeon.com by check, cashier's check or money order only!

Signature:_________________________________________Date Signed:_______________
DIRECTORY PLEDGE
By signing the above, I am stating that I am board-certified in plastic surgery by the American Board of Plastic Surgeons or the Royal College of Physicians and Surgeons of Canada, that my medical license in the state where I am practicing is current and has not been revoked (nor has it been revoked in any other state), and that I am not currently being investigated or disciplined for medical malpractice, or being considered for discipline for medical malpractice, by the Board of Medical Examiners of any state or country, nor has any Medical Board or comparable supervisory board deemed it necessary to bring disciplinary action against me in the past 5 years of longer.
I further state there have been no malpractice judgments or settlements against me for a minimum of 5 years.
I also promise to inform, immediately, the webmaster of www.BoardCertifiedPlasticSurgeon.com if the status of any of the above specifications have changed at any time during my listing period.
I understand that listing on BoardCertifiedPlasticSurgeon.com is at the sole discretion of the webmaster of BoardCertifiedPlasticSurgeon.com, I understand that my listing on BoardCertifiedPlasticSurgeon.com may be removed, and the remainder of the unused subscription fee, at a pro-rated monthly basis, up to 6 months, will be refunded to me. I agree with these terms and also agree not to take any legal action, and agree to forfeit the right to any and all legal action, against the webmaster or administrators of www.boardcertifiedplasticsurgeon.com for the removal of my listing.

Please mail completed, signed application and $125.00 fee (payable to BoardCertifiedPlasticSurgeon.com) to:
BoardCertifiedPlasticSurgeon.com, PO BOX 442, Pittston, PA 18640.

Terms

The terms of this agreement are for a limited time. The administrators of www.BoardCertifiedPlasticSurgeon.com reserve the right to change any and all terms and agreements without prior notice, and at our sole discretion. We also reserve the right to refuse to list any applicant, or to remove a listing, subject to a refund as set forth above, for any reason at any time, at our sole discretion. Please note that our administrators may check with applicable state Board of Medical Examiners/Board of Medicine to verify certain credentials. Thank you.
Copyright 2008 by BoardCertifiedPlasticSurgeon.com (sm) All Rights Reserved

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