Membership Application

ACOG District XII members are automatic members of FOGS and are eligible to participate in the FOGS practice benefit programs. For more information on any of the benefit programs contact the program managers directly from the benefit program home page here.

If you cannot provide a valid email address, you must use a print application. The print application can be downloaded here. It is STRONGLY suggested that you provide a valid email address that you check on a regular basis as many member benefits are transmitted electronically and depend on email transmissions.

Personal Information:

First Name:	Last Name:
Job Title:	Degree:
Email:	Birth Year(yyyy):

Office Information:

Street Line 1:	Street Line 2:
City:	State: Zip:
County:	Phone:
Fax:	Practice Name:
Office Manager Name:	Email box:

Home Address:

Street Line 1:	Street Line 2:
City:	State: Zip:
County:	Phone:
Fax:	Mail To: Bill To:

Education and Training:

Medical School	Grad Year	Degree

Professional and Postgraduate Training:

Program Name	Type	Specialty

Are you a Fellow/Member of the American College of Ob/Gyn?

Are you a member of the American College of Osteopathic Obstetricians and Gynecologists (ACOOG)?

Are you a professionally-trained healthcare practitioner (physician or allied health practitioner) in good standing in the medical community who can demonstrate that obstetrics and/or gynecology is your primary area of practice?

Do you have a current license to practice in Florida?
License #

We're sorry; you do not qualify for any currently available membership category as defined by FOGS bylaws. If you believe this is an error or you have a special case, please contact membership@flobgyn.org.

Mailing Lists:

NEW REQUIREMENTS BY FEDERAL GOVERNMENT: To receive blast faxes and blast emails from FOGS, please check the boxes below. Faxes and emails will only concern legislative alerts, special reimbursement notices, and meeting notices.

FOGS/PAC Email List

FOGS/PAC Blast Faxes

Membership:

Active
Osteopathic Obstetrician/Gynecologists who are active members of the American College of Osteopathic Obstetricians and Gynecologists (ACOOG), but are not members of ACOG District XII Florida.

Associate
Professionally trained practitioners (physicians and allied health practitioners) in good standing in the medical community who can demonstrate that obstetrics and/or gynecology are their primary areas of practice and have a current license to practice in Florida but are not active members of ACOG District XII Florida or ACOOG

Application fee: $50.00

First year Dues: $195.00

Total Charges: $245.00

Auto-Renew
Check this box if you would like to set up automatic annual renewal of your FOGS dues at $195 per year.

Please tell us why you want to join the Florida Obstetric and Gynecologic Society:

Reason:
Other:

Payment Information

*Name on Card (First Last)

Card Type:

*Card Number:

*Expiration(mm/yy):

*Security Code:

*Billing Zip Code: