Fellowship Program Application Leave this field blank Section 1 Application Type General Cosmetic Surgery Facial Cosmetic Surgery 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 No 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 No 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 No 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 No N/A Have you passed FLEX? Yes No N/A Have you passed ECFMG, FMGEMS? Education Commission for Foreign Medical Graduates / Foreign Medical Graduate Examiners in Medical Science Yes No N/A Have you passed the National Board of Dental Examiners? Yes No 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 No License to practice medicine in any jurisdiction Yes No Staff membership status or clinical privileges at any hospital, clinic or health care institution Yes No Membership/fellowship in local state, state, or national professional organizations Yes No Specialty board certification/eligibility Yes No License to practice any profession in any jurisdiction Yes No Faculty appointment at any medical or other professional school Yes No 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 No 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 No 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 No 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 LinkedIn 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 Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. DEA-BNDD Certificate Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. National Board Certificate, FLEX Certificate and/or ECFMG/FMGEMS Certificate (optional) Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Malpractice Insurance Facing Sheet (optional) Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Medical School Diploma Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Unmounted (3'x5') recent photograph Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Curriculum Vitae Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Additional Supporting Documents (optional) Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. 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 Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Recommendation Writer #2 Letter of Recommendation #2 Submit as a .pdf or .docx Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Recommendation Writer #3 Letter of Recommendation #3 Submit as a .pdf or .docx Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. 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. Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Disclosure / WaiverBy 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. Review reply Save draft
