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Special Notice to Members

By renewing your membership in the American Society for Reproductive Medicine (ASRM), you signify that you accept the goals, standards and disciplinary policy of the Society. ASRM is an equal opportunity organization and does not discriminate due to race, color, religion, age, gender, sexual orientation, national origin, citizenship, disability, military status or other basis prohibited by law.

All ASRM Members are requested respectfully to answer the following questions.

Name:
Email Address:
(required; format: yourname@isp.com)
Yes   No  Have you been convicted of a felony or of any offense (felony/misdemeanor) involving your professional activities?
Yes   No  Has any certificate of qualification or license to perform your professional activities in any state, province or country been suspended, revoked, restricted, curtailed or voluntarily surrendered under threat of suspension or revocation?
Yes   No  Have you had professional privileges at any healthcare facility revoked, suspended, curtailed, limited or restricted?
Yes   No  Have you been denied a certificate of qualification or license to practice your profession in any state or has your application for a certificate of qualification or license been withdrawn under threat of denial?
Yes   No  Have you been found lacking in providing professional services by any licensing Board/Agency?
If the answers to any of the above questions are yes, please explain: 

 


 

 

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