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Fellowship Program Application

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Section 1

Application Type

Applicant First name

Applicant Last name

Credentials (MD, DO, DMD, DDS)

Address Line 1

Address Line 2 (optional)

City

State (optional)

Zip/Postal Code (optional)

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 (optional)

Naturalized? (optional)

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 (optional)

End Date: Month/Year (optional)

Section 2

Military Record

Were you in the U.S. Armed Forces?

Yes

If Yes, What Branch? (optional)

Rank (optional)

Type of Duty (optional)

List and special skills acquired during actiy duty (optional)

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 (optional)

Licensure Number (optional)

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 (optional)

Specialty Board Eligible

Subspecialty (optional)

Subspecialty Board Certified Date (optional)

Subspecialty Board Eligible (optional)

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? (optional)

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 (optional)

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. (optional)

If more space needed send additional information to Kvanzandt@cosmeticsurgery.org

How did you first hear about the AACS certified Fellowship Program?

AACS Website

AACS Email

Facebook

CareerMD.com

StudentDoctorNetwork.com

Current or Former Training Fellow, please list name below

Fellowship Program Director, please list name below

Residency Director, please list name below

Medical Colleague, please list name below

Other: (optional)

Referring Physician: (optional)

Facial Fellowship Programs: (optional)

Daria Hamrah, DMD - Nova Surgicare, VA

Tanuj Nakra, MD - TOC Eye and Face, TX

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

Soheila Rostami, MD - Rostami OPC, VA

Randy Sanovich, DDS - Dallas Surgical Arts, TX

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

General Cosmetic Surgery Fellowships: (optional)

Scott Blyer, MD, DDS-Cameo Surgery Center, NY

Joseph Castellano MD-Castellano Cosmetic Surgery Center MD, FL

Angelo Cuzalina, MD, DDS-Tulsa Surgical Arts, OK

Phu Do MD FAACS-Aesthetic Surgery Institute, TX

J. Kevin Duplechain, MD - LA

Clayton Frenzel, DO - Bodevolve, TX

Bryan Friedman, DO - Friedman Plastics, AZ

Jacob Haiavy, MD - Inland Surgical, CA

Robert Jackson, MD & Chris Lowery, DO-Hamilton Surgical Arts, IN

Victoria Karlinsky, MD - VK Cosmetic Surgical Arts, FL

Claudia Kim, MD - New You New Life, NY

James Koehler, MD - Eastern Shore Cosmetic Surgery, AL

Mark Mandell-Brown,MD-Mandell-Brown Plastic Surgery Center ,OH

Tony Mangubat, MD - La Velle Vie Cosmetic Surgery Center, WA

Scott Moradian, DO - Avana Plastic Surgery, FL

Erik Nuveen, MD, DMD - Cosmetic Surgery Affiliates, OK

Pablo Rivera Jr, MD - Elite Cosmetic Surgery, TX

Michael Rodriguez, MD - Forever Young & Trim, FL

Alberico Sessa, MD - Sarasota Surgical Arts, FL

Alex Sobel, DO - Anderson Sobel, WA

Anh-Tuan N. Truong, MD - Chicago Breast and Body Aesthetics, IL

Drake Vincent, MD, DMD - Vincent Surgical Arts, UT

Suzanne W. Yee, MD-Dr. Suzanne Yee Cosmetics and Laser Surgery Center, AK

Talon Maningas, DO - Maningas Cosmetic Surgery, MO

Chad Deal, MD & Andrew Ray, DO - Southern Surgical Arts, TN

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 (optional)

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Malpractice Insurance Facing Sheet (optional)

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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 (optional)

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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

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Recommendation Writer #2

Letter of Recommendation #2

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Recommendation Writer #3

Letter of Recommendation #3

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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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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.

Last name

Email address

Comments or Questions: (optional)

Desired Fellowship Type

Do you currently meet the qualifications as listed for eligibility in the program?

Your Current Primary Surgical Specialty:

Please indicate in which U.S. State or other countries you hold a current medical license

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Other

If 'other' for above please indicate which country you hold a current medical license (optional)

Target Start Month:

Target Start Year:

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