Candidate Membership Application

 

Candidate Application form

Candidate members must:

  1. Shall express an interest in microsurgery
  2. Applicants must be enrolled in or completed a residency program that includes microsurgery training.
  3. Candidate member must apply for Active membership status within 1 year of board certification otherwise there will be a loss of membership.
  4. Applicants are to be proposed and sponsored by an Active or Associate member.

It is recommended that candidates have published or presented papers in recognized forums or publications. Other letters of recommendation from those familiar with your professional activities are welcomed.

Rights and duties of Candidate members:
Candidate members may attend scientific meetings and social functions. Candidate members may serve on committees, vote, and hold office. This category is valid for 5 years, or longer based on special circumstances.

 

Please type or print this application

Active_____ Associate ______ Corresponding ______ Candidate __X___

PERSONAL DATA

Name

 

Office Address
City/State/ZipCode
Office Telephone
Office Fax
E-Mail

 

Home Address
City/State/ZipCode
Home Telephone
Date of Birth/Place of Birth
Citizenship
Name of Spouse
Please indicate preferred mailing address: Home or Office

 

PROFESSIONAL QUALIFICATIONS

Pre-medical School
Name

 

Location

 

Dates/Degree

 

 

Medical School
Name

 

Location

 

Dates/Degree

 

 

Internship or PGY 1
Name

 

Location

 

Dates/Type

 

 

Residency
Name

 

Location

 

Dates/Type

 

Residency
Name

 

Location

 

Dates/Type

 

 

RESIDENCY TRAINING IN MICRONEUROVASCULAR SURGERY

Inclusive Dates Location Names of Director of Training Program
        
        
        

 

 

PRACTICE START DATE AND LOCATION (if applicable) ___________________________________________________________

 

MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS

Date Admitted Organization
   
   
   
   
   

 

PRESENTATIONS RELATED TO MICRONEUROVASCULAR SURGERY
Include title of meeting, title of presentation, location, and date. Attach additional information if necessary.

1.


2.


3.


4. 

 

ATTENDANCE AT PREVIOUS ANNUAL MEETING(S)
Please list ASRM annual meetings you have attended:


1.


2.


3.


4.

 

THE YOUNG MICROSURGEONS GROUP

The vision of the Young Microsurgeons Group is to unite young microsurgeons through active membership in the society and to enhance the voice and representation of younger members in the society. The Young Microsurgeon's Group will help coordinate educational experiences tailored to their membership and have a voice on select ASRM committees. Social activities will also be organized to foster camaraderie and provide opportunities to meet and interact with more senior members.

  YES I would be interested in participating in the YMG
  No thank you

 

 

SPONSORSHIP INSTRUCTIONS

Candidates for membership are to be proposed and sponsored by one Active or Associate member of the ASRM. Please print your sponsor’s name and information below. The ASRM Central Office will follow up with him/her and request a short statement of support.

 

Name:

 

Email Address:

  

Date:

 

Other letters of recommendation from those familiar with your professional activities are welcomed. The Membership Committee is particularly interested in receiving letters from chiefs of service of the hospitals, clinics, and universities in which you have trained and worked.

Send, to the address, below your completed, signed application along with the following:

  1. A copy of your current curriculum vitae.
  2. Any other information which may be of relevance to the Membership Committee.
  3. Current black and white photograph.

Signature of Applicant ________________________________________________

Date __________________

Send your completed application to:

American Society of Reconstructive Microsurgery
Central Office
20 N. Michigan Avenue, Suite 700
Chicago, IL 60602
(312) 456-9579
Fax (312) 782-0553

Microsurg

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