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Physician Application
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Applicant Name
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First
Last
Company Name
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Email
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Address
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Line 1
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City
State
Zip Code
Country
Phone Number
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License Number
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Date of Birth
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Years Licensed in Florida
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Why are you interested in FACTS?
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Have there been any administrative actions against your license in Florida or any other state? Explain the circumstances & resolution.
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Additional qualifications to be considered (education, other licenses held, public service, etc.)
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How did you find out about FACTS:
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Friend or Colleague Referral
Search Engine
Publication
Have you ever had a prior membership in FAPIA revoked or suspended? If yes, please describe the circumstances.
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Attach a photo for your FACTS ID Card
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Max file size: 20MB
Any photo showing a clear portrait of applicant's face. Does not need to be cropped as we will adjust the image to our requirements.
By submitting this application I attest that all information on this application is true and accurate to the best of my knowledge. I will comply with the Bylaws and membership rules of FACTS if my membership is approved. If my license is suspended or revoked by Florida Department of Health for any reason, I agree that my membership will also be suspended for the same period of time.I understand that my membership fee is non-refundable.
Company Phone Number
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Website
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Select other states you are licensed as a Physician
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Home
About
Contact
Board Of Directors
Become a Member
Physician Application