New Member Registration

Name:*

First Name Required Last Name Required

Age:* Age is Required

Gender:* Gender is Required

Male Female

Name of Hospital: Name of Hospital is not valid

Cellphone Number:* Cellphone Number is Required

Home Address::* Home Address: is Required

Upload the Deposit Slip Image:* Upload the Deposit Slip Image is Required

Senior Citizen / PWD ID (ONLY):* Senior Citizen / PWD ID (ONLY) is Required

Designation:* Designation is Required

PRC Number : :* PRC Number : is Required

PRC Expiration Date:* PRC Expiration Date is Required

Do you belong to National Capital Region or a Regional Chapter?:* Do you belong to National Capital Region or a Regional Chapter? is Required

National Capital Region Regional Chapter

Kindly indicate your PSA Regional Chapter. If you belong to National Capital Region, click N/A:* Kindly indicate your PSA Regional Chapter. If you belong to National Capital Region, click N/A is Required

PMA Number:* PMA Number is Required

Diplomate No. (If none, kindly write “N/A”):* Diplomate No. (If none, kindly write “N/A”) is Required

Diplomate Year:* Diplomate Year is Required

Are you a PSA Fellow? (FPSA):* Are you a PSA Fellow? (FPSA) is Required

Yes No

Birth Date:* Birth Date is Required

Name of Spouse (If none, kindly write “N/A”):* Name of Spouse (If none, kindly write “N/A”) is Required

Complete Name of Beneficiary #1 (Leave blank if not applicable): Complete Name of Beneficiary #1 (Leave blank if not applicable) is not valid

Complete Name of Beneficiary #2 (Leave blank if not applicable): Complete Name of Beneficiary #2 (Leave blank if not applicable) is not valid

Complete Name of Beneficiary #3 (Leave blank if not applicable): Complete Name of Beneficiary #3 (Leave blank if not applicable) is not valid

Complete Name of Beneficiary #4 (Leave blank if not applicable): Complete Name of Beneficiary #4 (Leave blank if not applicable) is not valid

Kindly indicate your status as a practicing anesthesiologist*:* Kindly indicate your status as a practicing anesthesiologist* is Required

Active Inactive Retired Delinquent

Kindly indicate your classification as a PSA Member:* Kindly indicate your classification as a PSA Member is Required

Resident Trainee Non-Diplomate Diplomate (DPBA) Fellow (FPSA)

Years Actively Practicing as an Anesthesiologist (Including Number of Years in Residency Training) (If retired, kindly indicate how many years of active practice you have had):* Years Actively Practicing as an Anesthesiologist (Including Number of Years in Residency Training) (If retired, kindly indicate how many years of active practice you have had) is Required

Name of Primary Hospital Affiliation (If none, kindly write “N/A”):* Name of Primary Hospital Affiliation (If none, kindly write “N/A”) is Required

City of Primary Hospital Affiliation (If no indicated hospital affiliation, kindly write N/A):* City of Primary Hospital Affiliation (If no indicated hospital affiliation, kindly write N/A) is Required

Regions of Primary Hospital Affiliation (If no indicated hospital affiliation, kindly click write N/A):* Regions of Primary Hospital Affiliation (If no indicated hospital affiliation, kindly click write N/A) is Required

Name of Secondary Hospital Affiliation (If none, kindly write “N/A”):* Name of Secondary Hospital Affiliation (If none, kindly write “N/A”) is Required

City of Secondary Hospital Affiliation (If no indicated hospital affiliation, kindly write “N/A”):* City of Secondary Hospital Affiliation (If no indicated hospital affiliation, kindly write “N/A”) is Required

Regions of Secondary Hospital Affiliation (If no indicated hospital affiliation, kindly write N/A):* Regions of Secondary Hospital Affiliation (If no indicated hospital affiliation, kindly write N/A) is Required

Name of Other Hospital Affiliation (If none, kindly write “N/A”):* Name of Other Hospital Affiliation (If none, kindly write “N/A”) is Required

City of Other Hospital Affiliation (If no indicated hospital affiliation, kindly write N/A):* City of Other Hospital Affiliation (If no indicated hospital affiliation, kindly write N/A) is Required

Region of Other Hospital Affiliation (If no indicated hospital affiliation, kindly write N/A):* Region of Other Hospital Affiliation (If no indicated hospital affiliation, kindly write N/A) is Required

College of Medicine Attended :* College of Medicine Attended is Required

Year Graduated from College of Medicine:* Year Graduated from College of Medicine is Required

Residency Training Hospital / Institution (If no indicated hospital affiliation, kindly write N/A:* Residency Training Hospital / Institution (If no indicated hospital affiliation, kindly write N/A is Required

Year Graduated from Residency Training:* Year Graduated from Residency Training is Required

Type of Fellowship/Subspecialty::* Type of Fellowship/Subspecialty: is Required

Name of Fellowship Hospital / Institution (Kindly indicate N/A if not applicable): Name of Fellowship Hospital / Institution (Kindly indicate N/A if not applicable) is not valid

Year Graduated from Fellowship Training (Kindly indicate N/A if not applicable): Year Graduated from Fellowship Training (Kindly indicate N/A if not applicable) is not valid

Email:* Invalid Email

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