PDF Application Active Members Application Date:* MM slash DD slash YYYY Name:* First Middle Last M.D./D.O./Other Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone:*Email:* Date of Birth:* MM slash DD slash YYYY Place of Birth:* Certified by American Board of Obstetrics and GynecologyBasic Certification Date:* MM slash DD slash YYYY Recertification Date(s):* MM slash DD slash YYYY SubspecialtySubspecialty Maternal Fetal Medicine Reproductive Endocrinology Gynecologic Oncology Other Subspecialty Fellowship Completed Fellowship Completed Fellowship Completed Fellowship Completed Subspecialty Certified Certified Certified Certified Other Certification: Date: MM slash DD slash YYYY Medical LicensureState and License #:* Expiration: MM slash DD slash YYYY State and License #: Expiration: MM slash DD slash YYYY Current Mode of Practice (Check all that apply)Subspecialty Solo Group Subspecialty Private Practice Hospital Based Practice Subspecialty Academic Part Time Academic Full Time Subspecialty Military Other Other Certification: Date: MM slash DD slash YYYY Application Must Be Endorsed by an ACTIVE member of the central Association and the endorser must send a letter of recommendation to the secretary of the society under separate cover.ENDORSED BY (Name):* Date:* MM slash DD slash YYYY THIS THIS COMPLETED FORM, LETTER OF ENDORSEMENT AND $100.00 FEE MUST BE RECEIVED IN THE ADMINISTRATION OFFICE BY JULY 1ST OF THE YEAR IN WHICH THE APPLICATION FOR MEMBERSHIP IS TO BE CONSIDERED. A completed CV is acceptable but it should include all pertinent information as listed below:1. Premedical Education 2. Medical Education 3. Residency Training 4. Other Postgraduate Education 5. Hospital Affiliations (past and present) 6. Hospital Committee Appointments (past and present) 7. Teaching Appointments (past and present) 8. Teaching Experience (past 5-10 years) 9. Medical Society Memberships 10. Medical Society Committees (past and present) 11. Community Activities (church, civic clubs, charitable organizations, etc.) Qualifications for MembershipCAOG Mission Statement The purpose of the Central Association of Obstetricians and Gynecologists is to promote optimal health care of women by providing high-quality continuing medical education and a forum for advancing and discussing scientific research in obstetrics, gynecology and women’s health care. The CAOG is committed to addressing the concerns of a diverse group of community and academic obstetricians and gynecologists by fostering an atmosphere of collegiality, mutual respect, scientific inquiry and mentoring among its members. Central Association Guidelines Pertaining to Membership: Types of Members: The Association shall be composed of seven types of membership: (1) Active, (2) Provisional Active, (3)Non-Resident, (4) Life, (5) Emeritus, (6) Adjunct, and (7) Honorary. Membership in the Association shall be available without regard to race, color, creed, gender, sexual orientation or national origin. Active Members. (a)Physicians in good professional standing, residing in the twenty-nine “central states” of Alabama, Arizona, Arkansas, Colorado, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Ohio, Oklahoma, South Dakota, Tennessee, Texas, Utah, West Virginia, Wisconsin and Wyoming. (b)Under special circumstances, and with the preapproval of the Board of Directors, an otherwise qualified physician not residing within the geographic confines of the Association may apply for active membership. (c)Physicians (1.) Who are Board Certified in OB/GYN (Diplomats of the ABOG or its equivalent) or (2.) Who are Board Certified in their specialties or its equivalent and have made major scientific contributions, basic or clinical to the specialty of OB-GYN. (c)An application for membership, listing such information as may be requested but including training received, official positions held, the scientific publications of the candidate, and endorsement by one (1) Active Member with a letter of recommendation, shall be submitted through the CAOG Office to the Membership Committee and then to the Board of Directors. (d)Upon nomination by the Board of Directors, the candidates shall be voted upon at the next Annual Meeting. A 2/3 affirmative vote of all Members entitled to vote and present at the meeting shall constitute election as a Provisional Active Member. (e)Each Provisional Active Member must attend one of the two Annual Meetings immediately following election in order to become a full Active Member. Failing attendance at the second Annual Meeting could automatically terminate the election process. List ANY meetings of The Central Association that you have attended. (Press + for more rows)CityYear Click + to add more rowsUpload CV FileMax. file size: 300 MB.Letter of RecommendationMax. file size: 300 MB.Or send to CAOG Office CAOG PaymentsPlease be certain that the following items have been completed: All areas of the application are complete CV attached Letter of recommendation by endorser has been sent to the CAOG Office Application signed and sent to the CAOG Office by July 1st Application fee of $100.00 paid All information given above is accurate and correct. Falsification is grounds for expulsion from the CAOG. If elected to membership, I agree to abide by the bylaws, rules and regulations of The Central Association of Obstetricians and Gynecologists. Applicant's Name* Questions: 701-838-8323 | Rhickel@caog.orgDate* MM slash DD slash YYYY CAPTCHA
