BoardCertifiedPlasticSurgeon.com (sm) Directory Application Page 2 of 2 - Must be accompanied by Page 1 (Information Page) Current Fee for NEW or LAPSED surgeons: $125.00 per surgeon & per city/ $75.00 six month option Discounted Fee for timely renewals (see Invoice) *Fee is for 12 months. Payment to DVDEALS 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of Physicians and Surgeons of Canada, that my medical license in the state where I am practicing is current and has not been revoked (nor has it been revoked in any other state), and that I am not currently being investigated or disciplined for medical malpractice, or being considered for discipline for medical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 - 2009 by BoardCertifiedPlasticSurgeon.com (sm) All Rights Reserved

Copyright 2008 - 2010 by BoardCertifiedPlasticSurgeon.com (sm) All Rights Reserved