FSP Membership Application

If you cannot provide a valid email address, you must use a print application. The print application can be downloaded here. It is STRONGLY suggested that you provide a valid email address that you check on a regular basis as many member benefits are transmitted electronically and depend on email transmissions.

PLEASE READ BELOW, YOUR APPLICATION WILL BE
IMMEDIATELY REJECTED IF:

Any required section is not completed.
You provide false or misleading information.
You attempt to circumvent any data validation implemented by the system.

Choose a Membership Type

Regular Member ( 1 year @ $450.00 )
Physicians residing in the state of Florida who are licensed to practice medicine as an M.D. or D.O. in the state of Florida. Regular members must dedicate a major portion of their practice to Pathology, and must either be Diplomates of the American Board of Pathology or eligible for admission to the examination of that Board, as certified by said Board.

New Practitioner ( 1 year @ $300.00 )
Physicians who are in their first or second year of practice may join FSP in this category. It is noted that beginning third year of practice, you will be automatically changed to a Regular Member and the membership dues amount will increase to $450.

Resident/Fellow in Training Member ( 1 year @ $0.00 )
Resident Members shall be physicians in the State of Florida who are in a full time approved training program in Pathology or sub-specialty of Pathology.

Corresponding Member ( 1 year @ $350.00 )
Corresponding Members shall include physicians who are practicing Pathology whose primary practice is in a State other than Florida, and is a member in good standing of a State society of pathology, other than the Florida Society of Pathologists. They shall have no vote at general or special meetings.

Retired Member ( 1 year @ $0.00 )
Retired Membership is available to any retired or inactive pathologist residing in Florida, who will document prior active membership in any State pathology society, the CAP, ASCP or other recognized National society of Pathology.

Military/VA/USPHS Members ( 1 year @ $300.00 )
Military members are pathologists who are federal employees that are primarily employed by the U.S. Military, U.S Public Health Services (USPHS), or Veterans Affairs (VA).

Personal Information

Courtesy Title:

First Name:

Middle Name:

Last Name:

Suffix:

Degree:

Other Degrees

Personal Email:

Work Email:

Job Title:

Date of Birth:

Gender:

How did you hear about the FSP?

Why are you joining?

Please tell us why you want to join the Florida Society of Pathologists.

Reason:

Were you referred by another member of the FSP?

If you were referred by a FSP member, please enter the information below.

Yes No

First Name

Last Name

FSP Account Information

The following two fields will establish a web account for you, once your application has been approved, allowing you to access members-only features on our website. Your username may consist only of letters and numbers and may not contain spaces.

Username:

Password:

By applying for membership in the Florida Society of Pathologists (FSP), you are agreeing that we may communicate with you INDIVIDUALLY by email, land mail and mobile phone for purposes directly related to your membership such as membership information and other purposes related to the maintenance of your account. Additionally, by default, you will be subscribed to our electronic communications such as newsletters, meeting announcements and educational opportunities which will be sent most often via email and on rare occasions may also be sent by text message. By entering your mobile number you authorize FSP, or it’s designated vendor to send text messages (SMS and MMS). Text messages are sent using auto-dialed technology to the wireless number you use to subscribe. Message and data rates may apply. If you do not wish to receive these communications, you may uncheck the boxes below. You may change these preferences at any time once your membership has been activated. We hope you'll stay subscribed. We promise to keep our communications concise, relevant and worth reading.

I authorize the FSP to send me text message communications related to my membership and the association ( 1-2x per month )

I authorize the FSP to send me email communications related to my membership and the association ( 1-2x per week )

Let us know if you would like to be included in the "Find a Pathologist" search feature.

Contact Information

Choose mailing preference:

Office Address

Organization:

Street Line 1:

Street Line 2:

City:

State:

Zip/Postal Code:

Office Phone:

Home Address

Street Line 1:

Street Line 2:

City:

State:

Zip/Postal Code:

Cell Phone:

About Your Practice

Profession:

Type of Practice:

Professional, Practice, or Organization Website (if applicable):

Are you with the:

Where are you employed?

Resident/Fellow

Are you applying as a resident or fellow?. Please select option below

Reason:

Education History

Medical or Graduate School:

Location:

Degree:

Year:

Residency (Postgraduate Training):

Location:

Degree:

Year:

Fellowship (Postgraduate Training):

Location:

Degree:

Year:

Board Certifications

Florida License:

In Effect and Unqualified?

American Board of Pathonlogy Number

AP Board:

CP Board:

APCP Board:

Other Board

Year Eligible

Year Certified

Teaching and/or Hospital Appointments and Memberships

1. Hospital or Medical School Name

Location

Dates

2. Hospital or Medical School Name

Location

Dates

Medical Society Memberships

Member of FMA?

Member of CAP?

County Medical Society:

Other Medical Society:

Optional Political Committee (PC) Donation

One-time Political Committee (PC) Donation

Suggested Amount - $1000
Other Amount

Monthly (1 Year) Political Committee (PC) Donation

Suggested Amount - $100
Other Amount

No contribution

Promo Code:

Payment Information

Cardholder's First Name:

Cardholder's Last Name:

Expiration Date:

Card Type:

Card Number:

CVV:

Zip/Postal Code:

AutoPay Dues Renewal:

Enroll in AutoPay and receive a 5% discount! By checking the box above, I agree to enroll in AutoPay. FSP will charge the provided credit card the published membership fee on the agreed upon date selected below of each year for membership dues. The FSP will notify me by email 60 days prior that the payment is occurring. I may cancel the automatic payment by contacting FSP in writing at least 30 days prior to the payment occurring.

AutoPay Start Date:

I hereby make application for membership in the Florida Society of Pathologists. I agree to abide by all the rules and regulations of the Constitution and bylaws and such changes and amendments as may hereafter be properly adopted, to revocation of membership in the event that any of the statements hereinafter made by me are false. I hereby pledge myself to the highest ethical standard in the practice of pathology, and, if elected to membership in the Florida Society of Pathologists, shall conduct myself in conformity with the Principles of Medical Ethics of the American Medical Association. By checking this box, you agree to accept valuable membership information sent electronically.

Review Order

Publication Date:

Wednesday, March 23, 2016 - 12:45pm

Category:

Organization

Tags:

membership

Organization

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FSP Membership Application

PLEASE READ BELOW, YOUR APPLICATION WILL BE IMMEDIATELY REJECTED IF:

Choose a Membership Type

Personal Information

Why are you joining?

Were you referred by another member of the FSP?

FSP Account Information

Contact Information

Office Address

Home Address

About Your Practice

Resident/Fellow

Education History

Board Certifications

Teaching and/or Hospital Appointments and Memberships

Medical Society Memberships

Optional Political Committee (PC) Donation

Payment Information

User login

PLEASE READ BELOW, YOUR APPLICATION WILL BE
IMMEDIATELY REJECTED IF: