Please print this form and mail. See instructions below.
FLORIDA
SOCIETY OF NEONATOLOGISTS
Ensuring
that all newborns are given a healthy start
Membership Application
Full Name: |
||
Current Position: |
||
Business Address: |
||
Phones: |
Office: | Fax: |
Email Address: |
||
Are You a member of the Florida Medical Association? _____ Yes; _____ No.
Type of Membership Requested: _____ Regular; ____ Associate; _____ Special
| _______ initials |
Regular Membership. I am a licensed Florida physician whose practice is limited to Neonatology and who is board certified in neonatal-perinatal medicine or who are Board Eligible in Neonatal-Perinatal Medicine and will become certified within four (4) years of membership. Proof of eligibility for Perinatal Boards must be submitted to the Credentials Committee at the time of application for membership. If certified, a copy of the certificate must be enclosed with the application. |
| _______ initials |
Associate Membership. I am a physician who is in a fellowship training program in neonatal-perinatal medicine or a pediatrician with a special interest in Neonatology. Associate members may participate in society activities, but are not eligible for office and may not vote. |
| _______ initials |
Special Membership. I am a physician whose is board certified in neonatal-perinatal medicine, but whose practice is not limited to Neonatal Medicine (or who no longer actively practice Neonatal Medicine) but who may contribute significantly to the goal of the Florida Society of Neonatologists. Such members shall have the privileges and responsibilities of regular membership. |
Date of Application: _____/_____/_____ Signature: ______________________
Return application along with $50 dues check, a copy of your Curriculum Vitae and proof of board-eligibility or certification by mail to: FSN c/o Vanessa Martin, 7052 King Arthur Road North, Jacksonville FL 32211-4107 or fax to: (904) 244-3777.
--------------------------------------------------- FSN Office Use Only --------------------------------------------------
_____ $50 Dues ____ Board Certified ____Board eligible ____ Approval ______ Notification