Physician Application

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- Physician Application

* Indicates required field

Applicant Name *

First

Last

Company Name *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

License Number *

Date of Birth *

Years Licensed in Florida *

Why are you interested in FACTS? *

Have there been any administrative actions against your license in Florida or any other state? Explain the circumstances & resolution. *

Additional qualifications to be considered (education, other licenses held, public service, etc.) *

How did you find out about FACTS: *

Have you ever had a prior membership in FAPIA revoked or suspended? If yes, please describe the circumstances. *

Attach a photo for your FACTS ID Card *

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 *

Website *

Select other states you are licensed as a Physician *

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Submit

admin@myfloridafacts.org
(888) 511-1628
6804 SW 114 Place, Suite A, Miami, FL 33173

Home
About
Contact
Board Of Directors
Become a Member
- Physician Application