Membership Application

Membership Application

Before beginning this application please note the following documents are required for upload:

  1. Full CV
  2. Surgery Log - excel file listing patient ID (not name - can be patient number or initials), date of surgery, title of surgery for the most recent 24 months.
  3. Summary sheet - (download link) for the same 24-month period as surgery log.
  4. Copy of Active Membership Certificate from one of the following:
    • ASPS membership
    • AAFPRS membership
    • AAOHNS membership
    • Equivalent foreign national society

Other requirements:

  • Nonrefundable Application Fee of $250

    Payments may be sent online (see below) or by check made out to The Rhinoplasty Society and sent to:
    P.O. Box 441745, Jacksonville, FL 32222-0018

  • Must be board certified by one of the following:
    • American Board of Plastic Surgery
    • American Board of Otolaryngology
    • American Board of Facial Plastic Surgery
    • Foreign Board Equivalent

APPLICATION DEADLINE

All application materials must be received by the Executive Office by December 31, for the applicant to be considered for admission to membership at the Annual Meeting in the spring of the following year. If you have not previously attended an Annual Meeting, you must attend the meeting when your application is up for vote by the membership.

Failure to attend will not stop the vote; however, your membership will not go into effect until such time that you do attend an annual meeting. Please contact Jeanie Hodges in the Society Office with any questions at 904-786-1377.

MEMBERSHIP APPLICATION PROCEDURE

PLEASE NOTE: All required documents must be ready to upload before you begin filling out the application. Unfinished application information cannot be saved.

Required Uploads* Please keep each upload under 10 MB in size and note the acceptable formats:

Curriculum Vitae (doc, docx, pdf):

Surgery Log (xls/xlsx):

Summary sheet (xls/xlsx):

Copy of membership certificate (jpg, jpeg, gif, png, pdf):


Application is for:

Active MembershipAssociate Membership

To be eligible for Active membership you must average 30 rhinoplasty surgeries per year. If your average is less than that, please apply for Associate membership.


Personal Information

Name (required)

Date of Birth:

Birthplace:

BUSINESS INFORMATION

Office Address:

City:

Country:

Province / State:

Zip:

Telephone:

Fax:

Email Address (required):

Web Address:

EDUCATION

Undergraduate College:

Degree/Year:

Medical School:

Degree/Year:

Other Graduate School:

Degree/Year:

GRADUATE MEDICAL TRAININGS

Surgical Residency (Speciality, i.e. general, ENT, orthopedic):

Plastic Surgery Residencies, Preceptorships, Fellowships:

LICENSURE

Licensure State:


License Country:

License Number:

License Year:

CERTIFICATION

Certification by ABMS Specialty Board (or the foreign equivalent) and Dates:

OTHER INFORMATION

Hospital Affiliations/ Medical School Appointments and Dates:

Honors, Fellowships, Research, and Grants:

Rhinoplasty Lectureships/ Instructional, Postgraduate, Masters, Rhinoplasty Courses Taught:

Professional Society Memberships:

Committee Responsibilities, Offices held in Professional Societies:

PRIOR RHINOPLASTY SOCIETY ANNUAL MEETING ATTENDANCE

Location of Rhinoplasty Society Annual Meeting attended:

Year:

GENERAL QUESTIONS

Has membership in any medical society ever been denied, suspended, or revoked? (if yes, please give details below):
noyes



Have hospital privileges ever been denied, suspended, or revoked, or have you ever been placed on probation? (if yes, please give details below):

noyes



Have you ever had your medical license or narcotics license suspended or revoked, or have you been placed on probation by a licensing authority for any reason, including drugs or alcohol? (if yes, please give details below):

noyes



Are you currently under investigation by the ethics or judiciary committee of any medical society? (if yes, please give details below):

noyes



Have you ever been named a defendant in malpractice actions, past or pending? (if yes, please give details below):
noyes

SPONSORS

Sponsor 1:

Sponsor 2:

$250 Application Fee Paid By:

Paying OnlineWill send check

your application before proceeding to application fee payment. Then proceed to payment below:

To pay by credit card CLICK HERE

Or

Send check made out to The Rhinoplasty Society to:
P.O. Box 441745, Jacksonville, FL 32222-0018
(Please note your application will not be processed until application fee has been received)