OGS Membership Dues 2024


First Name
Middle Name
Last Name
Informal Name
Suffix
Title (MD/DO/Other)
Designation (FACS, FAAP, MPH, etc.)
Birthdate	?
Gender
Email (preferred)
Email (alternate)
Cell Phone

Licensure and Training
Grad Year
Medical School:
Residency Program:
Residency: Begin Year	End Year
GI Fellowship Program:
Fellowship: Begin Year	End Year
ABIM GI Board Certification #	Date of Certification ?
OH. License Number
Initial OH Licensure Date	?
Specialty
Subspecialty
First Year in Practice post-residency and training

Member of (check all that apply)
	AASLD ACG AGA ASGE ACP AMA OSMA

Office Information
Practice Group Name
Group Contact/Administrator
Office Address

City
State	Zip
Office Phone
Office Fax
Website:

Home Information
Home Address

City
State	Zip



OGS Membership:
Membership Options:
• $100 a year for gastroenterologists with an active Ohio License
• $75 a year for Mid-level Provider Membership (Nurse Practitioner and Physician Assistant)
• $50 a year for Associate Membership (Registered Nurses, Licensed Practical Nurses, Endoscopy Mangers and Office Managers, who are actively employed in a gastroenterology practice, ambulatory endoscopy or surgery center, or a hospital based endoscopy unit)
• FREE for students, residents, fellows and retired gastroenterologists




Attestation:

I affirm that the information provided is true to the best of my knowledge.

By submitting this application, I authorize the Ohio Gastroenterology Society to obtain information from societies, hospital staffs, members and any other source regarding this application and my qualifications for membership, which information, whether or not solicited by the Society, may be kept confidential by the Society.

- denotes required fields