PDF Application Adjunct Membership 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:* 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. Medical Licensure (current) 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 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. Adjunct 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 adjunct membership. (c) Physicians may apply for membership providing that they are in an approved OB/GYN residency/fellowship program or are post OB/GYN residency/fellowship not exceeding three years and are not Board Certified. The Applicant will complete an application for membership. (d) Upon nomination by the Membership Committee, the candidacy shall be acted upon by the Board of Directors at the annual board meeting. If approved the candidate will then become an Adjunct Member. (e) Once achieving requirements for Active membership, the Adjunct Member should apply for Active membership status within 2 years and can become an active member even if residing outside the CAOG area. An Adjunct Member should remain as such for only 3 years post all formal training if not otherwise eligible to apply for Active membership. (f) An Adjunct Member shall pay dues and assessments as an Adjunct Member, but will not have the right to vote or hold office. Any member whose major interests are no longer in obstetrics and gynecology or women’s health care may be dropped from membership by the Board of Directors. 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 officeCAOG PaymentsApplication 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. Please 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
