BoardCertifiedPlasticSurgeon.com (sm)
SPONSOR Application/Information Form - PAGE ONE
Sponsors MUST pass credential check and take our custom SPONSOR PLEDGE.
Sponsors receive placement on FRONT, STATE, CITY plus a PERSONAL page on our site and may be featured on BONUS pages, as well.

(attach separate sheets if necessary for all information)

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

Name as it should appear on listing:

Practice name:

Street address:

City/Town:

Listing city* or cities**:
*must be within 10 mi. of actual location
**in some cases, you may be listed in other nearby cities for no charge

Office hours:

Contact person:

Telephone:

Fax:

E-mail address:

Your current URL (web site address): http://_____________________________________
SPONSORS receive their own page on our site and also link to your personal page.
PLEASE NOTE: Any surgeon who agrees to sponsor a city page on BoardCertifiedPlasticSurgeon.com understands that the purchase of sponsorship automatically grants the administrators of this site permission to take and use relevant and necessary information and photos (of doctor and/or staff, NOT of patients) fom the above indicated URL (web address) for use in the creation of said sponsor surgeon's page on our site.
Sponsor fee covers all costs. We do NOT charge for updates and maintenance.

Photo enclosed: Yes____ No_____

Take Photo from web site:Yes____ No_______
Indicate URL of web site where photo can be found

No photo desired: (check one)Yes_____ No ______