New Jersey Chapter - American College of Surgeons
MEMBERSHIP APPLICATION
Email *
Name (Exactly as on NJ Medical License) *
ACS Fellowship Number
NJ Medical License #
Date Issued
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Birth Date
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Sex
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Address
Telephone #
E-mail Address *
Medical Education *
Medical Degree *
Medical Degree Year *
Specialty Area - Primary
Board Certifications
Active Hospital Appointments
Please answer the following.
Attach a full explanation to any questions answered "yes".
Have you ever been convicted of a felony crime?
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Has your license to practice medicine in any jurisdiction ever been suspended or revoked?
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Have you ever been the subject of disciplinary action by a medical license board, medical Society or hospital staff?
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I hereby release, and hold harmless from any liability or loss, the New Jersey Chapter, American College of Surgeons, their officers, agents, employees, and members for acts performed in good faith and without malice in connection with evaluating any application and my credentials and qualifications, and hereby release from any liability any and all individuals and organizations, who, in good faith and without malice provide information to the above named organizations, or to their authorized representatives, concerning my professional competence, ethical conduct, character and other qualifications form membership. Furthermore, I attest to the accuracy of information supplied on this application and understand that falsification of any information may result in denial or revocation of membership.
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