PNW Transplant Society Application

Personal Information

DOCUMENTS REQUIRED: Copies of board certifications and a color photo

Last Name*

First Name*

Middle Initial

Suffix

Degree

Other Academic Degrees

Birth Date*

MM

DD

YYYY

Photo

A recent photograph is required with your application. You can upload one here, or send one by email or mail later.
Specifications:
• A portrait color photo.
• Jpg or tif format, 300 dpi resolution

Primary Mailing Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

Practice Information

(non-medical professionals may also apply)

Transplant Practice

Clinic/Group Name

Secondary Practice

Type of Practice

Clinic/Group Name

Medical Licensing

State Medical License

Number	Date Issued

Other State Licenses

State	Number	Date Issued

Professional Specialty

Primary Specialty*

Board

Eligible
Certified
Neither

Secondary Specialty or Special Interest

Board

Eligible
Certified
Neither

Practicing in the PNW as of*

MM

DD

YYYY

Is this your first year of practice?

Yes
No

Education and Training

Medical School

Name	State	Year Graduated

Residency Institution

State	Began	Ended

Specialty

State	Began	Ended

Additional Training

State	Began	Ended	Course of Study

Professional & Practice Experience

Please list professional society memberships:

List in chronological order all practice experience. Please include time frame.

Additional Questions

Has your ability to practice medicine in any jurisdiction ever been limited, suspended, revoked, denied, not renewed or have proceedings toward any of those ends ever been instituted? If yes, list details below.*

Yes
No

Additional Details

Have your privileges at any hospital ever been suspended, denied, diminished, revoked or not renewed?If yes, list details below.*

Yes
No

Additional Details

Are there any medical malpractice actions in this or any other state pending against you presently? If yes, list details below.*

Yes
No

Additional Details

Have any judgments or settlements been made against you in professional liability cases in the last 10 years? If yes, list details below.*

Yes
No

Additional Details

Have you ever been denied professional liability insurance or has your policy ever been canceled. If yes, list details below.*

Yes
No

Additional Details

RELEASE FOR MEMBERSHIP TO PNW TRANSPLANT SOCIETY

In consideration of the PNW Transplant Society processing my application for membership, I grant permission and consent for you to obtain from all hospital affiliations, information regarding staff privileges, and actions relating thereto; and all information from former medical society affiliations, specialty organizations, and other organizations providing medical training including internship and residencies.

I agree to furnish the Society with all information relative to any claim or action filed against me for malpractice, and I authorize and consent for you to obtain from my insurance malpractice carrier any and all information regarding insurance coverage, premiums, claims, and actions against me.

I further authorize disclosure of information generally considered to be reliable which has a bearing on my professional competence, character, and ethical qualifications to all hospitals, and medical licensing or discipline boards who request such information.

I hereby release, and hold harmless from any liability or loss, the PNW Transplant Society, its officers, agents, employees, and members, for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and hereby release from any liability any and all individuals and organizations, who, in good faith and without malice, provide information to the Society, or to its authorized representatives, concerning my professional competence, ethical conduct, character and other qualifications for membership.

I further release from liability the Society, its officers, agents, employees, and members for the delivery of information to any third party as authorized herein, provided such delivery occurs prior to the acknowledged receipt, in the office of the Society, of a written notice or revocation of this release.

I hereby agree to abide by the By-Laws and the Principles of Medical ethics of the Society and agree upon approval of membership, that my membership in the Society shall be conditional upon continued compliance of the aforementioned; and I further agree to recognize and abide by the interpretation thereof by the authorized officers of the Society, reserving all rights of appeal as set forth in the By-Laws of this Society.

I HEREBY AFFIRM AND REPRESENT THAT ALL STATEMENTS, ANSWERS, AND INFORMATION CONTAINED IN THIS APPLICATION ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

I declare under penalty of perjury under the laws of the State of Washington that all statements, answer and information contained in this application are true and correct.

Electronic Signature Indicating Agreement*

Yes, I agree
No, I do not agree