{"id":2079,"date":"2025-04-14T00:30:35","date_gmt":"2025-04-14T00:30:35","guid":{"rendered":"https:\/\/cosmeticsurgery.org\/fellowships\/?page_id=2079"},"modified":"2025-12-09T16:13:05","modified_gmt":"2025-12-09T16:13:05","slug":"criteria","status":"publish","type":"page","link":"https:\/\/cosmeticsurgery.org\/fellowships\/criteria\/","title":{"rendered":"Fellowship Program Establishment"},"content":{"rendered":"\n<h3 class=\"gb-text-e8443566\"><span class=\"gb-shape\"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 36.7 3\"><path d=\"M0 0h36.7v3H0z\"><\/path><\/svg><\/span><span class=\"gb-text\">AACS Certified Cosmetic Surgery Fellowship Program Director must<\/span><\/h3>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Have a current valid medical licensure in the state in which the Fellowship Training Program is to be offered;<\/li>\n\n\n\n<li>Maintain hospital&nbsp;transferring privileges and\/or another mechanism to transfer patients to a hospital;&nbsp;<\/li>\n\n\n\n<li>Be board certified by the American Board of Cosmetic Surgery (General Fellowship) or the American Board of Facial Cosmetic Surgery (Facial Fellowship);<\/li>\n\n\n\n<li>Hold a fellow membership in&nbsp;the American Academy of Cosmetic Surgery;<\/li>\n\n\n\n<li>Agree to site visitation at the onset of the program and review every five years to maintain facility and training accreditation;<\/li>\n\n\n\n<li>Plan to attend the AACS Annual Scientific Meeting and encourage&nbsp;Fellow Trainee(s)&nbsp;attendance as well;&nbsp;<\/li>\n\n\n\n<li>Provide regularly scheduled conferences with their Training Fellow(s) to discuss current literature and core curriculum;<\/li>\n\n\n\n<li>Willing to attend fellowship training sessions either through webinars or actual attendance at locations selected by the Fellowship Committees or AACS Board of Trustees;&nbsp;<\/li>\n\n\n\n<li>Encourage Training Fellow(s) to contribute to the scientific literature (or appropriate presentations) relative to the subject of cosmetic surgery (both basic scientific and\/or clinical materials);<\/li>\n\n\n\n<li>Complete the appropriate Training Fellow evaluation forms, and expect each Training will evaluate the Fellowship Program;<\/li>\n\n\n\n<li>Require all Training Fellows to maintain a current surgical case log of all procedures and must include at a minimum the date of the procedure, patient identification number, geographic location where the procedure was performed, type of anesthesia\/sedation, preoperative diagnosis, the operative procedure performed and the outcome of the procedure.&nbsp;<\/li>\n<\/ol>\n\n\n\n<p><em>I understand the above criteria. By continuing with the application process,&nbsp;I meet the Fellowship Program Director qualifications.<\/em><\/p>\n\n\n\n<p><strong>The following completed forms must be uploaded to your application:<\/strong><br><em>Please complete the appropriate case log for the fellowship you are applying for &#8211; Facial Cosmetic or General Cosmetic.<\/em><\/p>\n\n\n\n<div class=\"wp-block-uagb-container uagb-block-eeabffb5 alignfull uagb-is-root-container\"><div class=\"uagb-container-inner-blocks-wrap\">\n<div class=\"wp-block-uagb-container uagb-block-9ebc80fe\">\n<a class=\"gb-button gb-button-0c6630c3 gb-button-text\" href=\"https:\/\/cosmeticsurgery.org\/fellowships\/wp-content\/uploads\/2025\/04\/facial_summary_case_listing.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">&nbsp; &nbsp;&nbsp;FACIAL&nbsp;SURGICAL LOG SUMMARY<\/a>\n<\/div>\n\n\n\n<div class=\"wp-block-uagb-container uagb-block-85d52dc3\">\n<a class=\"gb-button gb-button-04511bca gb-button-text\" href=\"https:\/\/cosmeticsurgery.org\/fellowships\/wp-content\/uploads\/2025\/04\/1.20_case_listing_summary-fi.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">GENERAL SURGICAL LOG SUMMARY<\/a>\n<\/div>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-uagb-container uagb-block-381bdf55 alignfull uagb-is-root-container\"><div class=\"uagb-container-inner-blocks-wrap\">\n<div class=\"wp-block-uagb-container uagb-block-d671ad68\">\n<a class=\"gb-button gb-button-f0c00821 gb-button-text\" href=\"https:\/\/cosmeticsurgery.org\/fellowships\/wp-content\/uploads\/2025\/04\/Consent-Liability_Waiver_DOC.pdf\" target=\"_blank\" rel=\"noopener noreferrer\">Consent \/ Liability Waiver<\/a>\n<\/div>\n<\/div><\/div>\n\n\n\n<div style=\"height:50px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<hr class=\"wp-block-separator has-alpha-channel-opacity is-style-default\"\/>\n\n\n\n<div style=\"height:50px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"gb-text-7f8b3691\"><span class=\"gb-shape\"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 36.7 3\"><path d=\"M0 0h36.7v3H0z\"><\/path><\/svg><\/span><span class=\"gb-text\">AACS Clinical Fellowship Training Program Application<\/span><\/h2>\n\n\n\t\t\t<link rel=\"stylesheet\" property=\"stylesheet\" href=\"https:\/\/cosmeticsurgery.org\/fellowships\/wp-content\/plugins\/happyforms-upgrade\/bundles\/css\/frontend.css\" \/>\n\t\t\t\t<!-- HappyForms CSS variables -->\n\t<style>\n\t#happyforms-2620 {\n\t\t--happyforms-part-title-font-size: 16px;\n--happyforms-part-description-font-size: 12px;\n--happyforms-part-value-font-size: 16px;\n--happyforms-submit-button-font-size: 16px;\n--happyforms-color-primary: #000000;\n--happyforms-color-success-notice: #ebf9f0;\n--happyforms-color-success-notice-text: #1eb452;\n--happyforms-color-error: #f23000;\n--happyforms-color-error-notice: #ffeeea;\n--happyforms-color-error-notice-text: #f23000;\n--happyforms-color-part-title: #000000;\n--happyforms-color-part-value: #000000;\n--happyforms-color-part-placeholder: #888888;\n--happyforms-color-part-description: #454545;\n--happyforms-color-part-border: #dbdbdb;\n--happyforms-color-part-border-focus: #7aa4ff;\n--happyforms-color-part-background: #ffffff;\n--happyforms-color-part-background-focus: #ffffff;\n--happyforms-color-submit-background: #000000;\n--happyforms-color-submit-background-hover: #000000;\n--happyforms-color-submit-border: ;\n--happyforms-color-submit-text: #ffffff;\n--happyforms-color-submit-text-hover: #ffffff;\n--happyforms-color-table-row-odd: #fcfcfc;\n--happyforms-color-table-row-even: #efefef;\n--happyforms-color-table-row-odd-text: #000000;\n--happyforms-color-table-row-even-text: #000000;\n--happyforms-color-dropdown-item-bg: #ffffff;\n--happyforms-color-dropdown-item-text: #000000;\n--happyforms-color-dropdown-item-bg-hover: #f4f4f5;\n--happyforms-color-dropdown-item-text-hover: #000000;\n--happyforms-color-divider-hr: #cccccc;\n--happyforms-color-choice-checkmark-bg: #ffffff;\n--happyforms-color-choice-checkmark-bg-focus: #000000;\n--happyforms-color-choice-checkmark-color: #ffffff;\n--happyforms-color-rating: #cccccc;\n--happyforms-color-rating-hover: #000000;\n--happyforms-color-multistep-info-text-color: #000000;\n--happyforms-color-multistep-info-back-color: #000000;\n--happyforms-color-multistep-info-back-color-hover: #000000;\n--happyforms-poll-bar-color: #e8e8e8;\n--happyforms-poll-link-color: #000000;\n--happyforms-poll-winner-color: #000000;\n\t}\n\t<\/style>\n\t<!-- End of HappyForms CSS variables -->\n\t\t<!-- HappyForms Additional CSS -->\n\t<style data-happyforms-additional-css>\n\t\t<\/style>\n\t<!-- End of HappyForms Additional CSS -->\n\t\t\t<link rel=\"stylesheet\" type=\"text\/css\" href=\"https:\/\/cosmeticsurgery.org\/fellowships\/wp-content\/plugins\/happyforms-upgrade\/core\/assets\/css\/no-interaction.css\">\n\t\t<div class=\"happyforms-form happyforms-styles\" id=\"happyforms-2620\">\n\t\t\n\t<form action=\"\" id=\"happyforms-form-2620\" method=\"post\" novalidate=\"true\" autocomplete=\"off\">\n\t\t\t\t<input type=\"hidden\" name=\"happyforms_random_seed\" value=\"1754886021\" \/>\n\t\t\n\t\t\t<input type=\"hidden\" name=\"action\" value=\"happyforms_message\">\n\t\t\t\t<input type=\"hidden\" name=\"client_referer\" value=\"\">\n\t\t\t\t<input type=\"hidden\" name=\"current_post_id\" value=\"\">\n\t\t\t\t<input type=\"hidden\" name=\"happyforms_form_id\" value=\"2620\" \/>\n\t\t\t\t<input type=\"hidden\" name=\"happyforms_step\" value=\"0\" \/>\n\t\n\t\t<div class=\"happyforms-flex\">\n\t\t\t\t<label for=\"2620-multi_line_text\" class=\"screen-reader-text\">Leave this field blank<\/label>\n\t<input type=\"text\" id=\"2620-multi_line_text\" name=\"2620-multi_line_text\" style=\"display: none;\" tabindex=\"-1\" autocomplete=\"off\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_radio_7-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_7\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_7\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Fellowship Type<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_7_option_1746648778261\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_7\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">General Cosmetic Surgery Fellowship<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_7_option_1746648778266\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_7\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Facial Cosmetic Surgery Fellowship<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-quarter happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_2-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_2\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_2\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">First Name:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_2\" type=\"text\" name=\"2620_single_line_text_2\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-quarter happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_8-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_8\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_8\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Last Name:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_8\" type=\"text\" name=\"2620_single_line_text_8\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-quarter happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_9-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_9\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_9\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Suffix:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_9\" type=\"text\" name=\"2620_single_line_text_9\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-quarter happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_10-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_10\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_10\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Date:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_10\" type=\"text\" name=\"2620_single_line_text_10\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_11-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_11\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_11\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Address Line 1<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_11\" type=\"text\" name=\"2620_single_line_text_11\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_12-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_12\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_12\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Address Line 2<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_12\" type=\"text\" name=\"2620_single_line_text_12\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-third happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_13-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_13\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_13\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">City<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_13\" type=\"text\" name=\"2620_single_line_text_13\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-third happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_14-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_14\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_14\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">State<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_14\" type=\"text\" name=\"2620_single_line_text_14\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-third happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_15-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_15\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_15\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Zip\/Postal Code<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_15\" type=\"text\" name=\"2620_single_line_text_15\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--with-autocomplete happyforms-form__part happyforms-part happyforms-part--email happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_email_4-part\" data-happyforms-type=\"email\" data-happyforms-id=\"email_4\" data-happyforms-required=\"\">\n\t\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_email_4\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Your Email:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t<input type=\"email\" name=\"2620_email_4\" id=\"happyforms-2620_email_4\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_16-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_16\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_16\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Citizenship<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_16\" type=\"text\" name=\"2620_single_line_text_16\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_17-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_17\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_17\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Naturalized?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_17_option_1746649050157\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_17\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_17_option_1746649050161\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_17\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_18-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_18\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_18\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Person to notify in case of an emergency:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_18\" type=\"text\" name=\"2620_single_line_text_18\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--phone happyforms-part--width-half happyforms-part--label-show happyforms-phone--plain\" id=\"happyforms-2620_phone_19-part\" data-happyforms-type=\"phone\" data-happyforms-id=\"phone_19\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_phone_19\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Emergency contact phone number:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t<div class=\"happyforms-part-phone-wrap\">\n\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\t\t\t\t\t\t<input id=\"happyforms-2620_phone_19\" type=\"tel\" value=\"\" name=\"2620_phone_19[number]\" placeholder=\"555-555-5555\" autocomplete=\"off\" spellcheck=\"false\" \/>\n\t\t\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--layout_title happyforms-part--width-full\" id=\"happyforms-2620_layout_title_20-part\" data-happyforms-type=\"layout_title\" data-happyforms-id=\"layout_title_20\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t<h2 class=\"happyforms-layout-title\">HOSPITAL &amp; FREE-STANDING SURGICENTER AFFILIATIONS &amp; PRIVILEGES<\/h2>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_21-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_21\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_21\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Primary Hospital:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t<span class=\"happyforms-part__description\">Name, complete address, hospital administrator, phone &amp; department appointment.<\/span>\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_21\" type=\"text\" name=\"2620_single_line_text_21\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_22-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_22\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_22\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Secondary Hospital:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t<span class=\"happyforms-part__description\">Name, complete address, hospital administrator, phone &amp; department appointment.<\/span>\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_22\" type=\"text\" name=\"2620_single_line_text_22\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_23-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_23\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_23\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Surgicenter Affiliation:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t<span class=\"happyforms-part__description\">Name, complete address, hospital administrator, phone &amp; department appointment.<\/span>\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_23\" type=\"text\" name=\"2620_single_line_text_23\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_24-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_24\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_24\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Are these affiliations operated independent of you &amp; subject to independent quality &amp; peer review?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t<span class=\"happyforms-part__description\">If no, please explain on an addendum page.<\/span>\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_24_option_1746649284517\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_24\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_24_option_1746649284523\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_24\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_25-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_25\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_25\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Are you currently on the active medical staff at each of these facilities?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t<span class=\"happyforms-part__description\">If no, please explain on an addendum page.<\/span>\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_25_option_1746649284517\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_25\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_25_option_1746649284523\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_25\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_26-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_26\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_26\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Do you possess hospital privileges to perform cosmetic surgical procedures?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t<span class=\"happyforms-part__description\">If no, please explain on an addendum page.<\/span>\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_26_option_1746649284517\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_26\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_26_option_1746649284523\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_26\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_attachment_27-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_27\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_27\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"txt,pdf,docx,xlsx,docm\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_27\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Letter from hospital or surgicenter confirming surgical privileges for cosmetic surgery.<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_27[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_27[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_27[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_28-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_28\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_28\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Will hospital privileges be sought for all Fellowship applicants?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t<span class=\"happyforms-part__description\">If no, please explain on an addendum page.<\/span>\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_28_option_1746649284517\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_28\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_28_option_1746649284523\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_28\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_29-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_29\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_29\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Has any medical license been surrendered, suspended, or revoked?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_29_option_1746649284517\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_29\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_29_option_1746649284523\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_29\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_30-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_30\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_30\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Has the applicant ever been disciplined by any state or local medical board?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_30_option_1746649284517\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_30\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_30_option_1746649284523\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_30\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_attachment_31-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_31\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_31\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"txt,pdf,docx,xlsx,docm\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_31\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">If one of the previous 3 questions is yes, upload further information about the action(s).<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_31[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_31[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_31[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--layout_title happyforms-part--width-full\" id=\"happyforms-2620_layout_title_32-part\" data-happyforms-type=\"layout_title\" data-happyforms-id=\"layout_title_32\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t<h2 class=\"happyforms-layout-title\">FACILITY AND PERSONNEL INFORMATION<\/h2>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_33-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_33\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_33\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"txt,pdf,docx,xlsx,docm\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_33\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Verification of accreditation.<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_33[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_33[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_33[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--multi_line_text happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_multi_line_text_34-part\" data-happyforms-type=\"multi_line_text\" data-happyforms-id=\"multi_line_text_34\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_multi_line_text_34\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Practice facility square footage:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t<span class=\"happyforms-part__description\">List the location and square footage of each facility.<\/span>\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\t\t\t<textarea id=\"happyforms-2620_multi_line_text_34\" name=\"2620_multi_line_text_34\" rows=\"5\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\" autocorrect=\"off\" ><\/textarea>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_radio_36-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_36\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_36\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Has accreditation for the primary facility been:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_36_option_1746649621394\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_36\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Approved<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_36_option_1746649621402\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_36\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Denied<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_36_option_1746649621407\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_36\" value=\"2\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Applied for<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--multi_line_text happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_multi_line_text_35-part\" data-happyforms-type=\"multi_line_text\" data-happyforms-id=\"multi_line_text_35\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_multi_line_text_35\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">If denied, please explain:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\t\t\t<textarea id=\"happyforms-2620_multi_line_text_35\" name=\"2620_multi_line_text_35\" rows=\"5\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\" autocorrect=\"off\" ><\/textarea>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--checkbox happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_checkbox_39-part\" data-happyforms-type=\"checkbox\" data-happyforms-id=\"checkbox_39\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_checkbox_39\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Provision of sedation or anesthesia service, other than local, is primarily offered by:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"checkbox_39_option_1746649704886\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"checkbox\" class=\"happyforms-visuallyhidden happyforms-checkbox\" name=\"2620_checkbox_39[]\" value=\"0\" data-serialize  autocomplete=\"off\" spellcheck=\"false\"  >\n\t\t\t\t\t<span class=\"checkmark\"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"12\" height=\"12\" viewBox=\"0 0 24 24\"><path fill=\"currentColor\" d=\"M20.285 2l-11.285 11.567-5.286-5.011-3.714 3.716 9 8.728 15-15.285z\"\/><\/svg><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yourself<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"checkbox_39_option_1746649704897\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"checkbox\" class=\"happyforms-visuallyhidden happyforms-checkbox\" name=\"2620_checkbox_39[]\" value=\"1\" data-serialize  autocomplete=\"off\" spellcheck=\"false\"  >\n\t\t\t\t\t<span class=\"checkmark\"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"12\" height=\"12\" viewBox=\"0 0 24 24\"><path fill=\"currentColor\" d=\"M20.285 2l-11.285 11.567-5.286-5.011-3.714 3.716 9 8.728 15-15.285z\"\/><\/svg><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Staff<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"checkbox_39_option_1746649704903\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"checkbox\" class=\"happyforms-visuallyhidden happyforms-checkbox\" name=\"2620_checkbox_39[]\" value=\"2\" data-serialize  autocomplete=\"off\" spellcheck=\"false\"  >\n\t\t\t\t\t<span class=\"checkmark\"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"12\" height=\"12\" viewBox=\"0 0 24 24\"><path fill=\"currentColor\" d=\"M20.285 2l-11.285 11.567-5.286-5.011-3.714 3.716 9 8.728 15-15.285z\"\/><\/svg><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Anesthesia service<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"checkbox_39_option_1746649704908\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"checkbox\" class=\"happyforms-visuallyhidden happyforms-checkbox\" name=\"2620_checkbox_39[]\" value=\"3\" data-serialize  autocomplete=\"off\" spellcheck=\"false\"  >\n\t\t\t\t\t<span class=\"checkmark\"><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"12\" height=\"12\" viewBox=\"0 0 24 24\"><path fill=\"currentColor\" d=\"M20.285 2l-11.285 11.567-5.286-5.011-3.714 3.716 9 8.728 15-15.285z\"\/><\/svg><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Hospital only<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_38-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_38\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_38\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Are the participating physician(s) and anesthesia personnel certified in ACLS by the AHA?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_38_option_1746649677539\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_38\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_38_option_1746649677551\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_38\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--multi_line_text happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_multi_line_text_40-part\" data-happyforms-type=\"multi_line_text\" data-happyforms-id=\"multi_line_text_40\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_multi_line_text_40\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">If not, please identify status of personnel not certified and their responsibilities.<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\t\t\t<textarea id=\"happyforms-2620_multi_line_text_40\" name=\"2620_multi_line_text_40\" rows=\"5\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\" autocorrect=\"off\" ><\/textarea>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--multi_line_text happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_multi_line_text_41-part\" data-happyforms-type=\"multi_line_text\" data-happyforms-id=\"multi_line_text_41\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_multi_line_text_41\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Academic Appointment:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t<span class=\"happyforms-part__description\">Please describe your academic appointment and that of your faculty.<\/span>\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\t\t\t<textarea id=\"happyforms-2620_multi_line_text_41\" name=\"2620_multi_line_text_41\" rows=\"5\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\" autocorrect=\"off\" ><\/textarea>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--layout_title happyforms-part--width-full\" id=\"happyforms-2620_layout_title_42-part\" data-happyforms-type=\"layout_title\" data-happyforms-id=\"layout_title_42\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t<h2 class=\"happyforms-layout-title\">TRAINING PROGRAM INFORMATION<\/h2>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_43-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_43\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_43\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Is a state medical license required of all participating Fellow(s) while in the Fellowship Program?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_43_option_1746649782742\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_43\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_43_option_1746649782757\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_43\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--multi_line_text happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_multi_line_text_44-part\" data-happyforms-type=\"multi_line_text\" data-happyforms-id=\"multi_line_text_44\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_multi_line_text_44\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">If no, explain conditions relative to institutional licensure, permits,<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\t\t\t<textarea id=\"happyforms-2620_multi_line_text_44\" name=\"2620_multi_line_text_44\" rows=\"5\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\" autocorrect=\"off\" ><\/textarea>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_45-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_45\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_45\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Does your proposed Fellowship Training offer any monthly stipend?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_45_option_1746649824941\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_45\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_45_option_1746649824957\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_45\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--multi_line_text happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_multi_line_text_46-part\" data-happyforms-type=\"multi_line_text\" data-happyforms-id=\"multi_line_text_46\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_multi_line_text_46\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">If yes, please explain terms, amounts, (fixed or variable).<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\t\t\t<textarea id=\"happyforms-2620_multi_line_text_46\" name=\"2620_multi_line_text_46\" rows=\"5\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\" autocorrect=\"off\" ><\/textarea>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_47-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_47\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_47\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Does your proposed Fellowship Program provide medical malpractice coverage for Fellow(s)?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_47_option_1746649856925\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_47\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_47_option_1746649856950\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_47\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--multi_line_text happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_multi_line_text_48-part\" data-happyforms-type=\"multi_line_text\" data-happyforms-id=\"multi_line_text_48\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_multi_line_text_48\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">If yes, please list amount of coverage and carrier to underwrite.<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\t\t\t<textarea id=\"happyforms-2620_multi_line_text_48\" name=\"2620_multi_line_text_48\" rows=\"5\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\" autocorrect=\"off\" ><\/textarea>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_49-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_49\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_49\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Will Fellow(s) be given the opportunity to provide cosmetic surgical procedures as primary surgeon?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t<span class=\"happyforms-part__description\">When deemed appropriate, based on Fellow&#039;s background, experience and demonstrated abilities.<\/span>\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_49_option_1746649899571\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_49\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_49_option_1746649899592\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_49\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_50-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_50\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_50\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Will Fellow be required to submit\/report basic research to scientific publications?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_50_option_1746649899571\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_50\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_50_option_1746649899592\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_50\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--layout_title happyforms-part--width-full\" id=\"happyforms-2620_layout_title_51-part\" data-happyforms-type=\"layout_title\" data-happyforms-id=\"layout_title_51\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t\t<h2 class=\"happyforms-layout-title\">CONTINUING MEDICAL EDUCATION INVOLVEMENT<\/h2>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--single_line_text happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_single_line_text_52-part\" data-happyforms-type=\"single_line_text\" data-happyforms-id=\"single_line_text_52\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\t\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_single_line_text_52\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Number of required Continuing Medical Education hours for state licensure, per year:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t\n\t\t\t<div class=\"happyforms-input\">\n\t\t\t\t\n\t\t\t\t<input id=\"happyforms-2620_single_line_text_52\" type=\"text\" name=\"2620_single_line_text_52\" value=\"\" placeholder=\"\" autocomplete=\"off\" spellcheck=\"false\"  autocorrect=\"off\" \/>\n\t\t\t\t\t\t\t<\/div>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_53-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_53\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_53\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Are you in compliance with this requirement?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_53_option_1746649971355\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_53\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_53_option_1746649971380\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_53\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_54-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_54\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_54\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Do you currently participate as faculty in accredited cosmetic surgery CME courses?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_54_option_1746649971355\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_54\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_54_option_1746649971380\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_54\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-part--choice display-type--block happyforms-form__part happyforms-part happyforms-part--radio happyforms-part--width-half happyforms-part--label-show\" id=\"happyforms-2620_radio_55-part\" data-happyforms-type=\"radio\" data-happyforms-id=\"radio_55\" data-happyforms-required=\"\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_radio_55\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Have you contributed to medical literature relative to cosmetic surgery?<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_55_option_1746649971355\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_55\" value=\"0\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">Yes<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-part__option happyforms-part-option\" id=\"radio_55_option_1746649971380\">\n\t\t\t\t<label class=\"option-label\">\n\t\t\t\t\t<input type=\"radio\" class=\"happyforms-visuallyhidden\" name=\"2620_radio_55\" value=\"1\"  autocomplete=\"off\" spellcheck=\"false\" >\n\t\t\t\t\t<span class=\"checkmark\"><span class=\"happyforms-radio-circle\"><\/span><\/span>\n\t\t\t\t\t<span class=\"label-wrap\">\n\t\t\t\t\t\t<span class=\"label\">No<\/span>\t\t\t\t\t<\/span>\n\t\t\t\t<\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--placeholder happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_placeholder_56-part\" data-happyforms-type=\"placeholder\" data-happyforms-id=\"placeholder_56\">\n\t<div class=\"happyforms-part-wrap\">\n\t\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<p>If yes, please include examples in your Curriculum Vitae.<\/p>\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_57-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_57\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_57\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,txt,docm,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_57\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Curriculum Vitae<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_57[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_57[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_57[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_58-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_58\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_58\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,txt,docm,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_58\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Copy of current state license to practice medicine and surgery<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_58[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_58[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_58[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_59-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_59\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_59\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,txt,docm,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_59\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Copy of your current DEA-BNDD Certificate<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_59[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_59[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_59[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_60-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_60\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_60\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,txt,docm,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_60\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Copy of your current medical malpractice insurance face sheet<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_60[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_60[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_60[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_61-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_61\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_61\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,txt,docm,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_61\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Copy of your medical school diploma<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_61[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_61[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_61[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_62-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_62\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_62\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,txt,docm,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_62\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Your ABCS or ABFCS certificate<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_62[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_62[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_62[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_63-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_63\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_63\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,txt,docm,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_63\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Listing of affiliate faculty<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t<span class=\"happyforms-part__description\">Per the Guidelines, &quot;...the Program shall consist of no less than two (2) faculty members. &quot;<\/span>\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_63[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_63[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_63[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_64-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_64\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_64\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,jpg,jpeg,png\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_64\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Current photo<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_64[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_64[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_64[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_65-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_65\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_65\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,jpg,jpeg,png,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_65\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Signed Consent and Liability Waiver Form<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_65[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_65[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_65[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_66-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_66\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_66\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,txt,docm,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_66\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Surgical Case Listing Summary<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t<span class=\"happyforms-part__description\">Surgical Case Listing Summary<\/span>\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_66[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_66[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_66[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_67-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_67\" data-happyforms-required=\"\" data-happyforms-part-id=\"attachment_67\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"pdf,txt,docm,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_67\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">A surgical log for the clinic for the one year period preceding the application.<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file size is too big.<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t<ul class=\"happyforms-attachment__list\">\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t\t<script type=\"text\/template\" class=\"item-template\">\n\t\t\t\t<li class=\"happyforms-attachment-item\" data-attachment-id=\"\">\n\t<div class=\"happyforms-attachment-item__col happyforms-attachment-item__col--main\">\n\t\t<span class=\"happyforms-attachment-item__name\"><\/span>\n\t\t<span class=\"happyforms-attachment-item__size\"><\/span>\n\t<\/div>\n\t<div class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_67[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_67[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_67[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n<div class=\"happyforms-form__part happyforms-part happyforms-part--attachment happyforms-part--width-full happyforms-part--label-show\" id=\"happyforms-2620_attachment_68-part\" data-happyforms-type=\"attachment\" data-happyforms-id=\"attachment_68\" data-happyforms-part-id=\"attachment_68\" data-happyforms-max-file-size=\"128\" data-happyforms-max-file-count=\"0\" data-happyforms-allowed-file-extensions=\"csv,pdf,jpg,jpeg,png,ppt,docx\">\n\t<div class=\"happyforms-attachment happyforms-part-wrap\">\n\t\t\t<div class=\"happyforms-part__label-container\">\n\t\t\t\t<label for=\"happyforms-2620_attachment_68\" class=\"happyforms-part__label\">\n\t\t\t<span class=\"label\">Additional supporting documents:<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-required\"><\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"happyforms-optional\">(optional)<\/span>\n\t\t\t\t\t<\/label>\n\t\t\t<\/div>\n\t\n\t\t\n\t\t<div class=\"happyforms-part__el\">\n\t\t\t\n\t\t\t<div class=\"happyforms-upload-area happyforms-input-group with-suffix\">\n\t\t\t\t<input type=\"text\" class=\"happyforms-visuallyhidden\" tabindex=\"-1\" aria-disabled=\"true\">\n\t\t\t\t<div class=\"happyforms-attachment-box\">\n\t\t\t\t\t\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"default\">Choose file<\/div>\n\t\t\t\t\t<div class=\"happyforms-attachment-progress\" data-type=\"uploading\">Uploading\u2026 (<span>0<\/span>%)<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-input-group__suffix happyforms-input-group__suffix--button\">\n\t\t\t\t\t<button type=\"button\" class=\"happyforms-plain-button\" tabindex=\"-1\">Browse<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\n\t\t\t\n\t\t\t<div class=\"happyforms-file-notices\">\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"duplicate\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> A file with this name has already been uploaded.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"invalid\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 512\"><path fill=\"currentColor\" d=\"M504 256c0 136.997-111.043 248-248 248S8 392.997 8 256C8 119.083 119.043 8 256 8s248 111.083 248 248zm-248 50c-25.405 0-46 20.595-46 46s20.595 46 46 46 46-20.595 46-46-20.595-46-46-46zm-43.673-165.346l7.418 136c.347 6.364 5.609 11.346 11.982 11.346h48.546c6.373 0 11.635-4.982 11.982-11.346l7.418-136c.375-6.874-5.098-12.654-11.982-12.654h-63.383c-6.884 0-12.356 5.78-11.981 12.654z\" class=\"\"><\/path><\/svg> This file type isn\u2019t allowed.<\/p>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"happyforms-part-error-notice\" data-error-type=\"size\">\n\t\t\t\t\t<p><svg role=\"img\" aria-hidden=\"true\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" viewBox=\"0 0 512 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class=\"happyforms-attachment-item__col\">\n\t\t<button type=\"button\" class=\"happyforms-text-button happyforms-attachment-link happyforms-delete-attachment\">Delete<\/button>\n\t<\/div>\n\t<div>\n\t\t<input type=\"hidden\" name=\"2620_attachment_68[#][id]\" value=\"\" class=\"happyforms-attachment-input__id\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_68[#][name]\" value=\"\" class=\"happyforms-attachment-input__name\" \/>\n\t\t<input type=\"hidden\" name=\"2620_attachment_68[#][size]\" value=\"\" class=\"happyforms-attachment-input__size\" \/>\n\t<\/div>\n<\/li>\t\t\t<\/script>\n\n\t\t\t\n\t\t\t\n\t\t\t\t\t<\/div>\n\t<\/div>\n<\/div>\n\t\t\t\t\t\t<div class=\"happyforms-form__part happyforms-part happyforms-part--submit\">\n\t\t<button type=\"submit\" class=\"happyforms-submit happyforms-button--submit \">Send<\/button>\n\t<\/div>\t\t<\/div>\n\n\t\t\t<\/form>\n\n\t<\/div>\n\n","protected":false},"excerpt":{"rendered":"<p>AACS Certified Cosmetic Surgery Fellowship Program Director must I understand the above criteria. By continuing with the application process,&nbsp;I meet the Fellowship Program Director qualifications. The following completed forms must be uploaded to your application:Please complete the appropriate case log for the fellowship you are applying for &#8211; Facial Cosmetic or General Cosmetic. AACS Clinical &#8230; <a title=\"Fellowship Program Establishment\" class=\"read-more\" href=\"https:\/\/cosmeticsurgery.org\/fellowships\/criteria\/\" aria-label=\"Read more about Fellowship Program Establishment\">Read more<\/a><\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":4,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"Criteria & Responsibilities for Fellowship Program Directors %%sep%% %%sitetitle%%","_seopress_titles_desc":"Learn the qualifications and responsibilities to become the Director of an AACS-certified cosmetic surgery fellowship 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