Recognition belongs to the recipient.

Use the OGC number printed on your certificate to create the permanent administrative record and decide whether any information may appear in the public Golden Canary Registry.

Publication is optional. Declining publication does not affect your recognition. Contact information is administrative and is never published.

Recognition record

Fields marked * are required.

OGC number *Name and credentials *Professional role *State *Recognition year *Date of recognition *Presenting Golden Canary Representative *Hospital or organization (administrative unless separately approved below)

Public registry decision

Your choice affects publication only. It does not affect your recognition.

Yes, I authorize publication of only the items I select below. No, do not publish my information.

If yes, select each item that may be published:

Private administrative contact

This information is used to administer the recognition and is not published.

Email *Telephone (optional)

Separate optional permissions

These choices are independent of the registry decision and may be declined.

I permit photographs of me with the recognition to be used by the Order. I permit a story or testimonial that I separately provide or approve to be published by the Order. I would like occasional email updates from the Order and may unsubscribe at any time.

Electronic acknowledgment

By typing my name, I confirm that the information is accurate, the choices above are mine, and this typed name is my electronic signature. I understand that I may ask the Order to correct or remove a public registry entry by contacting the Founder.

Typed signature *Date signed * I have read and agree to the acknowledgment above.

Questions? Contact Founder@theorderofthegoldencanary.org.