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Fellowship Program Application

Section 1

Application Type *

Applicant First name *

Applicant Last name *

Credentials (MD, DO, DMD, DDS) *

Address Line 1 *

Address Line 2

City *

State

Zip/Postal Code

Country *

Phone *

Country code

Phone number

Email address *

Are you a current AACS member? *

Yes

I am submitting my application for complimentary membership to the AACS. *

Membership in the American Academy of Cosmetic Surgery (AACS) is required for participation in this program and is complimentary for 1 year. By selecting "Yes," you confirm that you are applying for membership and will be automatically enrolled.

Yes

Not Applicable - I am already a current member

Citizenship

Naturalized?

Yes

Person to Notify in case of Emergency *

Emergency Contact Phone *

Country code

Phone number

What year are you applying for? (Most programs start in January or July)

First Choice-Start Date: Month/Year *

End Date: Month/Year *

Second Choice- Start Date: Month/Year

End Date: Month/Year

Section 2

Military Record

Were you in the U.S. Armed Forces? *

Yes

If Yes, What Branch?

Rank

Type of Duty

List and special skills acquired during actiy duty

Section 3

State Medical or Dental Licensure

Licensure State *

Residents, if your state does not require a medical license, please note this in this field.

Licensure Date

Licensure Number

Drug Enforcement Administration Number *

Residents, if your state does not require a DEA number, please note this in this field.

Drug Enforcement Administration Date *

Specialty *

Specialty Board Certified Date

Specialty Board Eligible *

Subspecialty

Subspecialty Board Certified Date

Subspecialty Board Eligible

Have you passed the National Board of Medical Examiners - Part 1, 2 & 3? *

Yes

N/A

Have you passed FLEX? *

Yes

N/A

Have you passed ECFMG, FMGEMS? *

Education Commission for Foreign Medical Graduates / Foreign Medical Graduate Examiners in Medical Science

Yes

N/A

Have you passed the National Board of Dental Examiners? *

Yes

N/A

Section 4

Have any of the following ever been or are in the process of being denied, revoked, suspended, reduced, not renewed or voluntarily relinquished (by either resignation or expiration)?

Narcotic License, Drug Enforcement Administration or other controlled substances registration *

Yes

License to practice medicine in any jurisdiction *

Yes

Staff membership status or clinical privileges at any hospital, clinic or health care institution *

Yes

Membership/fellowship in local state, state, or national professional organizations *

Yes

Specialty board certification/eligibility *

Yes

License to practice any profession in any jurisdiction *

Yes

Faculty appointment at any medical or other professional school *

Yes

Do you have any health impairments that affect your ability to perform duties?

Do you have any health impairments that affect your ability in terms of skill, attitude or judgement to fully perform professional and medical staff duties?

Yes

Has your professional liability carrier been sued for your actions within the past five (5) years? *

Please include any information on malpractice claims or suits against you as well as any malpractice claims or suits that have been filed against you.

Yes

If Yes, include name of present and past insurance carriers & their consent to release information

Are there now or have there ever been any criminal charges against you? *

Yes

If 'Yes' to any question in Section 4 give a brief description.

If more space needed send additional information to [email protected]

Other:

Referring Physician:

Facial Fellowship Programs:

Daria Hamrah, DMD - Nova Surgicare, VA

C. Carson Huynh, MD, DMD, FACS, FAACS - Radiance Surgery & Aesthetic Medicine, GA

Husain Ali Khan, MD, DMD - Georgia Oral & Facial Reconstructive Surgery, GA

Tanuj Nakra, MD - TOC Eye and Face, TX

Carey Nease, MD - Nease Cosmetic Surgery, TN

Sami A. Nizam, II, MD, DMD Alabama Surgical Arts, AL

Jon Perenack, MD, DDS - Williamson Cosmetic Center, LA

Soheila Rostami, MD - Rostami OPC, VA

Randy Sanovich, DDS - Dallas Surgical Arts, TX

Section 5

Please upload a copy of the following documents

State License *

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DEA-BNDD Certificate *

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National Board Certificate, FLEX Certificate and/or ECFMG/FMGEMS Certificate *

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Malpractice Insurance Facing Sheet *

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Medical School Diploma *

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Unmounted (3'x5') recent photograph *

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Curriculum Vitae *

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Additional Supporting Documents

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Section 6

Please list the name and address of the three letters of reference you will be submitting or upload references.

Recommendation Writer #1 *

Letter of Recommendation #1

Submit as a .pdf or .docx

Submit if available (do not attach if being sent via 3rd party)

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Recommendation Writer #2 *

Letter of Recommendation #2

Submit as a .pdf or .docx

Submit if available (do not attach if being sent via 3rd party)

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Recommendation Writer #3 *

Letter of Recommendation #3

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Submit if available (do not attach if being sent via 3rd party)

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Statement of Interest *

The statement of interest is an excellent opportunity to succinctly communicate how your background and career interests make you a good candidate for a cosmetic surgery fellowship and how a cosmetic surgery fellowship fulfills a career goal.

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Training Fellow Candidate Match Agreement *

Electronically sign Training Fellow Candidate Match agreement and attach here.

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Disclosure / Waiver
By submitting this form you certify that the information contained in this application is complete and you are capable and qualified for the training program. Any misstatement in or omission from this application constitutes cause for dismissal from the program. You also understand that the American Academy of Cosmetic Surgery (AACS) only facilitates the collection of Fellowship applications and is in no way part of the Fellow-in-Training selection process.

You authorize AACS and the Fellowship Directors to consult and seek information regarding your present and past liability and qualifications. AACS and Fellowship Directors reserve the right to review any submitted documentation.

You hereby release from liability AACS and the Fellowship Directors for their acts performed in good faith without malice in connection with evaluating you and your credentials or in providing information concerning your application for the training program.

As of January 1, 2026, a new application fee will apply: $150 for…

Email address

Phone

Country code

Phone number

Comments or Questions: (optional)

Your Current Primary Surgical Specialty:

Target Start Year:

I agree to allow this site to store and process the personal information submitted.

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