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 Newsletter Member List

Membership Application: (please print)

Please complete membership application form along with two (2) Society member endorsement signatures and return to the HGOS Office along with a check in the amount of $210, made payable to HGOS. The $210 payment is for annual dues of $200 and $10 processing fee which will include your Society membership certificate.



Name:(Last, First, Middle)
_________________________________		 Age:_______

Office Address:______________________________________________________

Office Tel No.: ______/_________________		 Fax: ______/___________________

Home Address: ______________________________________________________

Email Address: ______________________________________________________

Date Of Birth: _________________________

Citizen of the United States (circle one):
Y
N

Dates of Military Service: ________________ to __________________

Branch of Service: ____________________________________________________


Rank

(induction): __________________

to (separation) ______________________

Awards: ___________________________________________________________
 
Signature of Applicant: _________________________________ Date: __________


To the Houston Gynecological & Obstetrical Society:

We vouch for the character and standing of _____________________________ M.D., and recommend his/her election to active membership.

Sponsored by: (Signature)
_____________________________________________

(Print Name)

_____________________________________________

Endorsed by: (Signature)
_____________________________________________

(Print Name)

_____________________________________________


Society Record (for Society use only)

Date application received: ______________________________________________

Action of Counsil:
_____ Approved
_____ Deferred
_____ Dropped

Action of Society:
_____ Elected
_____ Rejected
Date: ___________

Roster No.: _____________________
Date Issued_____________________

P.O. Box 272865, Houston TX. 77277-2865
Phone: 713-661-1839 Fax: 713-661-1303

To the Houston Gynecological Society:

For your information, I submit the following data concerning my medical education and surgical training.

1. Premedical Education (University or College):

___________________________19___ to 19___ Degree __________________

___________________________19___ to 19___ Degree __________________

2. Medical Education

___________________________19___ to 19___ Degree __________________

___________________________19___ to 19___ Degree __________________

3. Internship

___________________________19___ to 19___ Degree __________________

___________________________19___ to 19___ Degree __________________

4. Residencies

(Hospitals, Dates, and position in hospitals)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

(Investigative work during this period)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

5. Surgical experience, investigative and other postgraduate work in addition to obstetrical and/ or gynecological fellowship or residency; in medical school and dispensaries (under whose guidance); in experimental laboratories; in clinics; in postgraduate courses; etc.

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

6. Hospital Appointments (dates)

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

7. Teaching Appointments (include dates)

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

8. Practice limited to: _______________________________________________

9. Member of the following medical and surgical societies

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

10. Certification American Board of Obstetrics and Gynecology:

Name of Board ___________________________________

Date _____________

11. List of Chief Contributions to Medical and Surgical Literature with date and place of publication

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

 
HGOS  •  P.O. Box 272865  •  Houston, Texas 77277
Phone 713 661 1839 • FAX 713 661 1303 • Email: Lisa Gasper