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BoardCertifiedPlasticSurgeon.com (sm)
Directory Application Page 1 of 2 - MUST be acompanied by Page 2 (signed and dated DIRECTORY PLEDGE) Current Fee New / Lapsed Surgeons: $125.00 per surgeon & per city/ $75.00 six month option SPECIAL OFFER/ RENEWAL FEE: submit our letter as proof with payment. *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): | ||||||||||||||||||||||||||||||||||||||||||
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Practice street address:
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| Practice City/Town/Zip Code: | ||||||||||||||||||||||||||||||||||||||||||
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*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 total of 8 procedures frequently performed by you:
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| List Office Hours (if desired): | ||||||||||||||||||||||||||||||||||||||||||
| Contact person: ___________________________ E-Mail:_________________________________ Publish? Yes or No | ||||||||||||||||||||||||||||||||||||||||||
| Office Telephone:___________________________ Fax#_______________________________Publish Fax?_____ | ||||||||||||||||||||||||||||||||||||||||||
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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: | ||||||||||||||||||||||||||||||||||||||||||
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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 - 2010 by BoardCertifiedPlasticSurgeon.com (sm) All Rights Reserved | ||||||||||||||||||||||||||||||||||||||||||