Membership Form Step 1 of 3 33% Today Date Format: MM slash DD slash YYYY Please choose the option that best describes you:*I am applying to be a new member.I am renewing my membership.Contact InformationName* First Last Credentials (MD, DO, etc) Practice / Group NamePractice Email* Home/Personal Email* Preferred Email for SGS Correspondence*Practice EmailHome/Personal EmailPractice Email Preferred* Practice Home Preferred Email* Home Practice PhoneHome PhonePreferred Phone for SGS CorrespondencePractice PhoneHome/Personal PhonePractice Phone Preferred* Practice Home Phone Preferred* Home Practice Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Preferred Address for SGS CorrespondencePractice AddressHome/Personal Address My Practice Is My Preferred Address for SGS Correspondence * My Home Is My Preferred Address for SGS Correspondence Preferred Email Preferred PhonePreferred Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EducationPre-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 CertificationMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Board Eligible*YesNoPofessional Society Memberships One-Year Membership DuesMembership 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. 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 - $300.00Candidate Membership - $300.00Junior Physician Membership - $250.00Affiliate Physician Membership - $300.00Area Member - $100.00Affiliate Non Physician Membership - $250.00In-Training Member - $100.00Resident Member - $0.00Premium Level - $500.00 Make a DonationWould you consider making a tax deductible donation to SGS this year? PaymentCoupon Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 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.CAPTCHA