THE AMERICAN BOARD OF HOSPITAL PHYSICIANS

APPLICATION FOR MEMBERSHIP AND BOARD CERTIFICATION AS A

DIPLOMATE OF THE AMERICAN BOARD OF HOSPITAL PHYSICIANS

(PLEASE CHECK ONE OF THE FOLLOWING:)

             I   WANT  TO  APPLY  FOR  MEMBERSHIP  AND  I  WANT  TO  BE  CERTIFIED  AS  A  DIPLOMATE  OF  THE  AMERICAN  BOARD  OF  HOSPITAL  PHYSICIANS     (FEE  IS  $300.) 
                    (I  UNDERSTAND  THAT I  WILL  ALSO  BE  CERTIFIED  AS  A  DIPLOMATE  OF  THE  AMERICAN  COLLEGE  OF  ETHICAL  PHYSICIANS)

APPLICATION  FORM:
I AGREE TO THE CODE OF ETHICS AS SET FORTH BY THE AMERICAN COLLEGE OF ETHICAL PHYSICIANS

  NAME:

  MEDICAL  DEGREE:

  OTHER UNIVERSITY  DEGREES:

  DATE  OF  BIRTH:

   MAILING  ADDRESS: STREET AND NO.:      

  MAILING ADDRESS: IF SUITE OR APARTMENT GIVE NO.:

   MAILING  ADDRESS: CITY:

   MAILING  ADDRESS: STATE :

  MAILING  ADDRESS: COUNTRY:

   MAILING ADDRESS: ZIP CODE:

   E-MAIL:

  PLEASE ANSWER THE FOLLOWING QUESTIONS (ALL INFORMATION GIVEN IS KEPT STRICTLY CONFIDENTIAL):

  HAVE YOU EVER BEEN ELIGIBLE FOR CERTIFICATION BY ANY TYPE OF MEDICAL BOARD?
  YES     NO

  PLEASE INDICATE THE BOARDS TO WHICH YOU HAVE BEEN ELIGIBLE:


  HAVE YOU EVER BEEN CERTIFIED BY ANY MEDICAL BOARD OF ANY KIND OR BY ANY MEDICAL SPECIALTY BOARD?  YES     NO

  PLEASE INDICATE ANY PRESENT BOARD CERTIFICATION:               

  HAVE YOU WORKED AT ANY HOSPITAL NOW OR IN THE PAST? YES     NO

 PLEASE INDICATE THE NAME OF EACH HOSPITAL IN THE PAST:

 PLEASE INDICATE THE NAME OF EACH  PRESENT HOSPITAL:

  DO YOU PROMISE TO  ALWAYS UPHOLD AND MAINTAIN A HIGH LEVEL OF CARE  TO  ALL  OF  YOUR  PATIENTS?   YES     NO

  DO YOU PROMISE TO UPHOLD THE HIGH STANDARD OF THE AMERICAN BOARD OF HOSPITAL PHYSICIANS? YES     NO

  DO YOU PROMISE TO ENDEAVOR TO BRING HONOR AND PRESTIGE TO YOURSELF, YOUR FAMILY, YOUR COUNTRY, THE HONORABLE PROFESSION OF MEDICINE, AND TO THE AMERICAN BOARD OF HOSPITAL PHYSICIANS ? YES      NO

  THE FOLLOWING QUESTION IS OF GREAT IMPORTANCE IN THOSE HEREBY ON THE VERGE OF BEING BOARD CERTIFIED BY THE AMERICAN BOARD OF HOSPITAL PHYSICIANS:
  WILL YOU TRY AT ALL TIMES TO PROVIDE THE LATEST AND MOST THOROUGH AND EFFECTIVE TREATMENT OF ALL HOSPITAL PATIENTS WITHOUT REGARD FOR THEIR ABILITY TO PAY, OR THEIR SEX, OR THEIR SEXUAL ORIENTATION, OR THEIR RACE, OR RELIGION, OR CREED, OR COUNTRY,OR  WHETHER OR NOT THEY HAVE INSURANCE, AND NO MATTER WHAT THEIR NEED, WITHIN REASON, AND WHATEVER TYPE OF PATIENT OR TYPE OF ILLNESS, OR WHETHER THE PATIENT IS A PRIVATE PATIENT OR AN HMO PATIENT OR A PUBLIC AID PATIENT, OR ANY HUMAN BEING WHO IS IN NEED OF TREATMENT? YES

  PLEASE NOTE: ALL FUNDS RECEIVED BY THE AMERICAN BOARD OF HOSPITAL PHYSICIANS WILL BE RETURNED IN THE EVENT AN APPLICANT IS FOUND NOT TO BE WORTHY OF MEMBERSHIP OR BOARD CERTIFICATION AS A DIPLOMATE OF THE AMERICAN BOARD OF HOSPITAL PHYSICIANS.

  PLEASE NOTE: SINCE THE PROFESSION OF MEDICINE IS AN HONORABLE PROFESSION AND SINCE PHYSICIANS DEDICATE THEMSELVES TO SAVING LIFE AND HELPING HUMANITY, ALL ANSWERS GIVEN BY PHYSICIANS WILL BE CONSIDERED HONEST AND TRUE IN THE BOARD'S EVALUATION OF AWARDING BOARD CERTIFICATION AS A DIPLOMATE OF THE AMERICAN BOARD OF HOSPITAL PHYSICIANS.

  PLEASE INDICATE ON THE SPACE BELOW EXACTLY HOW YOU WANT YOUR NAME AND DEGREE TO APPEAR ON YOUR CERTIFICATE AS A  DIPLOMATE:     
     

  CERTIFICATES WILL BE SENT BY CERTIFIED MAIL WHEN POSSIBLE.

  PAYMENT MAY BE MADE BY CHECK OR MONEY ORDER.
  MAKE CHECK OR MONEY ORDER  PAYABLE TO:     
                   THE AMERICAN BOARD OF HOSPITAL PHYSICIANS
  SEND TO:   AMERICAN BOARD OF  HOSPITAL PHYSICIANS    
                                       PORT  DE  LEAU  PLAZA                                                                       
                                                  SUITE  434                                                                                                         
                                           2158 - 45th STREET                                                                                  
                                    HIGHLAND, INDIANA, 46322