AAOCG Membership Application

Are you currently a practicing OB/GYN performing liposuction & other cosmetics?
Fill out the form below to become a member:
Membership application fee $300

First Name  
Last Name  
Middle Initial  
Business Address  
City  
State  
Zip  
Country  
Phone  
Fax  
Email  
Website  
Home Address  
City  
State  
Zip  
Country  
Home Phone  
Cell Phone  
Preferred Mail  
Preferred Phone  
Date of Birth  
Place of Birth  
Medical License#  
Medical Specialty
State / Country  
Date Obtained  
Is your license in effect and unrestricted yes no
Board certified yes no
Which board  
Date certified  
ABMS area(s) of surgical training  
Active membership in  
List accredited cosmetic workshop(s) and dates attended  
Cosmetic procedures currently performing  

By clicking the submit button below, I agree that membership in the American Academy of Cosmetic Gynecologists (AAOCG) is a privilege not a right. I recognize that the contents of this application will be seen by individuals working for AAOCG. I agree to surrender my membership and return my certificate if my license to practice medicine is revoked, suspended or limited beyond its present state, or if membership is revoked or terminated for such other cause as may be provided by the bylaws of the Society. Moreover, I acknowledge that membership in AAOCG does not qualify me as a certified physician to practice cosmetic procedures, and that membership alone in said Society is for educational purposes to advance knowledge and experience. Additionally, I agree to adhere to all rules regulations and policies as adopted by AAOCG. I furthermore understand that membership in AAOCG does not give me license to perform cosmetic procedures. Instead, it expresses my interest and participation in the studying of techniques. I hereby acknowledge and authorize use of the information I have provided for dissemination of information from or approved by AAOCG which it deems germane to my practice.
 
Your name  
Today's date  
Download the AAOCG Membership Application and fax to 520.574.7944 or mail completed form & payment to:
American Academy of Cosmetic Gynecologists
8000 S Kolb Rd, Ste 101
Tucson, AZ 85706