Membership Form

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• Please choose the option that best describes you:*
  • I am applying to be a new member.
  • I am renewing my membership.

• Contact Information

• Name*
  First Last Credentials (MD, DO, etc)
• Practice / Group Name
• Practice Email*
• Home/Personal Email*
• Preferred Email for SGS Correspondence*
  • Practice Email
  • Home/Personal Email
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  Practice Email Preferred*
  • Practice
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  Home Preferred Email*
  • Home

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• Practice Phone
• Home Phone
• Preferred Phone for SGS Correspondence
  • Practice Phone
  • Home/Personal Phone
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  Practice Phone Preferred*
  • Practice
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  Home Phone Preferred*
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• Practice Address
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Home Address
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Preferred Address for SGS Correspondence
  • Practice Address
  • Home/Personal Address
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  • My Practice Is My Preferred Address for SGS Correspondence
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  • My Home Is My Preferred Address for SGS Correspondence

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  Preferred Email
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  Preferred Phone
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  Preferred Address
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

• Education

• Pre-Medical Education
  (School Name/Location and Years Attended)
• Medical School
  (School Name/Location and Years Attended)
• Residency
  (School Name/Location and Years Attended)
• Fellowship
  (School Name/Location and Years Attended)
• Date of Board Certification
  MM123456789101112

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  YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
• Board Eligible*
  • Yes
  • No
• Pofessional Society Memberships

• One-Year Membership Dues

• Membership Categories

  Active Membership – $275 Early Bird / $300 Regular
  To be eligible as an Active Member, a person shall have been certified by the American Board of Obstetrics and Gynecology or the American Osteopathic Board of Obstetrics and Gynecology, and must be in practice in the State of Washington.
  
  Candidate Membership – $275 Early Bird / $300 Regular
  To be eligible as a Candidate Member, a person shall have satisfactorily completed the written portion of the examination for certification by the American Board of Obstetrics and Gynecology or the American Osteopathic Board of Obstetrics and Gynecology, and must be in practice in the State of Washington.
  
  Senior Level Membership – $200
  A previous Active member who remains in active practice and whose license to practice medicine is valid and unrestricted after having engaged in the practice of gynecology for a period of 20 years, and who has been an active member of the Seattle GYN Society for twenty years or more. The Senior Level includes all rights and privileges of Active Membership. New! Junior Physician Membership – $225 Early Bird / $250 Regular
  To be eligible as a Junior Physician Member, a person shall have satisfactorily completed the written portion of the examination for certification by the American Board of Obstetrics and Gynecology or the American Osteopathic Board of Obstetrics and Gynecology, and must be in practice in the State of Washington. The member must be in their first two years of practice outside of training. You are eligible for Junior Membership for two years.
  
  Affiliate Physician Membership – $275 Early Bird / $300 Regular
  Affiliate Membership is available for healthcare professionals who practice with or belong to a practice associated with an active fellow, such as a physician who practices OB/GYN who has not sought ABOG certification, a physician of a specialty other than Ob/Gyn. Affiliate Membership include all rights and privileges of Active Membership, except voting.
  
  Affiliate Non Physician Membership - $225 Early Bird / $250 Regular
  Affiliate membership is available for all mid-level healthcare professionals: RN, a nurse practitioner (ARNP), a Certified Nurse Midwife (CNM), a Licensed Midwife (LM), a Physician Assistant (PA-C), a Registered Nurse (RN), and Licensed Practical Nurse (LPN), or reproductive scientists. Affiliate Membership includes all rights and privileges of Active Membership, except voting.
  
  Area Membership – $75 Early Bird / $100 Regular
  Area Membership is established for those practicing outside of King, Pierce and Snohomish counties who find it difficult to attend dinner meetings. Area Members pay for dinners attended (they are currently $75 each).
  
  In-Training Physician Membership - $75 Early Bird / $100 Regular
  In-training membership is available for obstetrics and gynecology residents or fellows during their education program. In-training Membership includes all rights and privileges of Active Membership, except voting.
  
  Premium Level - $500
  A Premium Level includes Active Member membership as a person certified by the American Board of Obstetrics and Gynecology or the American Osteopathic Board of Obstetrics and Gynecology, that practices in the State of Washington. For the Premium Level you will also receive preferred seating at the SGS President’s Table at the Fall Assembly and at each Dinner Lecture Series evening event.
  
  
• Membership Category*
  • Active Membership - $300.00
  • Candidate Membership - $300.00
  • Senior Level Membership - $200.00
  • Junior Physician Membership - $250.00
  • Affiliate Physician Membership - $300.00
  • Area Member - $100.00
  • Affiliate Non Physician Membership - $250.00
  • In-Training Member - $100.00
  • Resident Member - $0.00
  • Premium Level - $500.00

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• Make a Donation
  Would you consider making a tax deductible donation to SGS this year?

• Payment

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• Credit Card*
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  Visa

  Supported Credit Cards: American Express, Discover, MasterCard, Visa

  Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date   Security Code Cardholder Name

• INQUIRIES Contact Kimberly Conn, Association Executive, at the SGS office at 206-956-3652 or send emails to admin@seagyn.org.

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