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SURGEON PROGRAM MEMBERSHIP APPLICATION

SURGEON PROGRAM MEMBERSHIP AGREEMENT

TO:      Fund Administrator, Police Surgeons Program

            Fraternal Order of Police – Amtrak Police Department Lodge #189

 

            I hereby apply to become a participating surgeon with the Amtrak Police Department Fraternal Order of Police Lodge # 189, Police Surgeon Panel. Each practice location will be identified in this agreement. Each treating Physician will sign this agreement. In the event that I choose to terminate my panel membership, I agree to notify your office in writing at least 30 days prior to the effective date of the decision. I understand that the organization reserves the right to terminate my participation in the Surgeon Panel. I understand that if either the panel or I decide to terminate this agreement, I will return all materials (Shield, Wallet, ID & Placard) pertaining to the organization.

 

I understand that it is illegal to represent myself as a Police Officer (you may identify yourself as an Amtrak Fraternal Order of Police Lodge Surgeon). I understand that it is illegal to possess an unlicensed firearm/weapon and I acknowledge that my status as an Amtrak Fraternal Order of Police Lodge Surgeon does not convey to me the right to possess firearms/weapons.

 

I will adhere to any correspondence I receive from the organization. In the event that I wish to advertise my status as a Participating Surgeon to the media, I agree to submit such advertisement for approval to the Lodge #189 Executive Board. The Executive Board or their representatives may conduct on-site visits and will investigate any grievances or complaints. I understand that I will be listed in the nationwide directory by specialty that will be distributed to the Fraternal Order of Police / Amtrak Police Department Lodge # 189 members. I understand that this agreement does not infringe upon my freedom of choice to accept a patient, nor does it put any constraints or limitations on my best clinical judgment in treatment.

 

My signature on this application indicates my agreement to accept all the provisions set forth in this application package.

SURGEON PROGRAM MEMBERSHIP INSTRUCTIONS

  1. All materials should be sent, unfolded and unstapled, to the name and address listed on the bottom of this page. 

  2. After signing this agreement, please provide the following:

    • COPY OF YOUR STATE LICENSE TO PRACTICE MEDICINE & CURRENT REGISTRATION

    • A CURRENT & BRIEF SUMMARY OR RЀSUMЀ

  3. Provide a Color Passport photos. Surname on back with soft tip pen

  4. Provide a check for $350.00 to cover the application fee and first year’s dues. 

  • This will also cover the cost of the Shield, Wallet, Placard and processing of the application.

  •  The annual dues are $175.00 payable by April 30th yearly

SURGEON PROGRAM MEMBERSHIP APPLICATION