Name: ________________________________ Date: _____________
Address: _________________________________________________________
Phone number: __________________ Fax number:_______________
E-mail address: _________________________________________________________ Medical School (Name, city, country, years, degree): ____________________________
Postgraduate Training (Type, school or proctor, dates):
Board Certification (Specialty, year):
_________________________________________________________
Years Practicing Cosmetic Surgery: ___________________________
Disciplinary Actions Taken by Any Medical Organization (explain):
__________________________________________________________
LIST THE SPECIALTY IN WHICH YOU WISH TO TAKE THE EXAMINATION (General Cosmetic, Dermatologic Cosmetic, Facial Cosmetic, Body Contouring):___________________________________

INSTRUCTIONS
1. Please attach a 2x2 inch photo to the application
2. The fee for filing the applications is 250 Euros (non refundable), the examination fee is 2,300 Euros plus International Academy of Cosmetic Surgery membership fee of 400 Euros. Total = $2950 Euros.
3. The completed application with fees must be received at least 60 days prior to the examination. Incomplete applications will not be accepted for the upcoming examination.
4. Attach a list of 100 cosmetic surgery cases with patient identification initials or number, the surgery performed, the date of surgery, and any postoperative complications of each patient. Of those 100 cases, 20 of them should include operative report, preoperative photos, and postoperative photos.
a. For general cosmetic surgery the cases must include at least:

i. 1 abdominoplasty
ii. 1 facelift
iii. 1 breast augmentation
iv. 1 breast reduction
v. 1 tissue augmentation using filler or implant (other than breast)
vi. 1 liposuction
vii. 1 blepharoplasty

b. For any specialty surgery (facial cosmetic surgery, dermatologic cosmetic surgery, or body contouring surgery) only a variety of cases within the specialty should be included.