BoardCertifiedPlasticSurgeon.com (sm) PO BOX 442, Pittston PA 18640 Directory Application Part I : listing is CUSTOM designed w/ your photo & practice information. Our Directory Pledge is PART II of the application process. The Directory Pledge must be signed, dated, and sent via U.S. Mail. We reserve the right to refuse to list, or remove, any surgeon at any time for any reason. Minimum Requirements / Fee questions, email: Marion@BoardCertifiedPlasticSurgeon.com Support appreciated, but please Read First - QUALIFIED? ~ Listing Benefits

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

Gender: male / female (circle one)     State & medical license #:

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:

URL / Online address:

*CITY DIRECTORY 1st CHOICE:_____________________ 2nd City:_______________ 3rd City:_________________________ * Surgeons may request to be listed in a city, town or borough within a reasonable driving distance from their practice. Additional city listings may be purchased at a fraction of 1st city cost.

Specialty (check one or both): Cosmetic______ Reconstructive_______ Subspecialty?__________________________________

PROCEDURES LIST: (additional room on back of this page.) COSMETIC PROCEDURES: RECONSTRUCTIVE:

HOSPITALS / FACILITIES: (additional room on back of this page.) Privileges / Appointments:

Office Hours:

Contact person: ___________________________ E-Mail:_________________________________ Publish? Yes or No

Office Telephone:___________________________

Month/Year Board Certified by American Board of Plastic Surgery or RCPSC: MOC-PS:__________________________________

Please mail completed, signed application and correct fee - payable to BoardCertifiedPlasticSurgeon.com: BoardCertifiedPlasticSurgeon.com, PO BOX 442, Pittston, PA 18640. Terms The terms of this agreement are for a limited time. The webmaster / administrator of www.BoardCertifiedPlasticSurgeon.com reserves 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. Application implies permission by applicant/surgeon for the webmaster of BoardCertifiedPlasticSurgeon.com to copy and use information from applicant's website, including any and all text and images (except for before & after photos of actual patients), for use in creation of applicant's listing on our site. 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 - 2019 by BoardCertifiedPlasticSurgeon.com (sm) All Rights Reserved

Directory Application: must be accompanied by - Directory Pledge