Corresponding Members Application

Corresponding members must:

  1. be physicians residing outside the U.S. or Canada.
  2. be board certified or have appropriate specialty qualifications in their country.
  3. demonstrate continuing interest and practice in reconstructive microneurovascular surgery.
  4. be sponsored by one (1) Active member and endorsed by two (2) additional Active or Corresponding members in good standing.
  5. have attended at least one previous annual meeting of the Society prior to application.

Rights and duties of Corresponding Members:   They shall pay annual Corresponding membership dues, and shall pay registration fees for meetings they attend. Corresponding members may not hold office.

Please type or print this application

Active______ Associate ______ Corresponding ___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

 

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

 

 

POST-RESIDENCY TRAINING IN MICRONEUROVASCULAR SURGERY

Inclusive Dates Location Names of Director of Training Program
 

 

 

 

 

 
 

 

 

 

 

 
 

 

 

 

 

 

 

LICENSURE

Licensed to practice medicine in:

State or Country Date License No
     
     
     

 

BOARD CERTIFICATION

Specialty boards completed:

Board Date
   
   

 

MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS

Date Admitted Organization
   
   
   
   
   

 

HOSPITAL AND UNIVERSITY STAFF AFFILIATIONS (subsequent to completing fellowship)

From / To Hospital or University and Department Name of Chief of Service Your Position
   

 

   
   

 

   
   

 

   
   

 

   
   

 

   
   

 

   

 

PROFESSIONAL ACTIVITIES

How long have you been in practice (after fellowship)?

 

How long in present position?

 

Number of operations performed last year?

 

How many of these were qualifying (see next page) microneurovascular cases?

 

 

LIST OF OPERATIVE PROCEDURES

Please enclose two copies of a typewritten list of

  1. all qualifying microneurovascular operative procedures performed during the last year including date, hospital or chart number, and patient initials;
  2. the total number of surgery cases performed in the same one-year period;
  3. the free flap cases performed during the preceding three-year period, including date, hospital or chart number, and patient initials.

Note: Neurolysis, carpal tunnel release and revision of previous free tissue transfer which are already contained in the case lists are not acceptable. List should include only microneurovascular cases organized into the following three categories:

  1. Limb or digit replantation or revascularization.
  2. Nerve repair or graft.
  3. Free tissue transfer.

Do not include other operative procedures. Only cases performed after the completion of residency and fellowship training are eligible. Sign your list certifying that you were the primary surgeon for these cases or explain your involvement in these cases.

 

PUBLICATIONS:

List each of your publications related to microneurovascular surgery, including the title, author(s), journal inclusive pages, and year. Attach additional information if necessary. Submit one copy of each paper with your application.

1.

 

2.

 

3.

 

4.

 

 

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)

Attendance at a previous Annual Meeting of the American Society for Reconstructive Microsurgery is required for application eligibility. Please list annual meetings you have attended:

1.
2.
3.
4.

 

INSTRUCTIONS

Candidates for membership must be sponsored by one Active member of ASRM, and endorsed by two additional Active or Corresponding members. It is recommended that one of these individuals be from the candidate's local geographical area. Each sponsor and endorser must sign the original application form and write a letter to the chairman of the ASRM Membership Committee supporting the candidate.

Sponsor

Name
Address

 

 

Signature

 

Endorser #1

Name
Address

 

 

Signature

 

Endorser #2

Name
Address

 

 

Signature

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. Two copies of your list of qualifying microsurgical procedures performed in the past year (12- month period).
  2. Reprints of your published work in microsurgery.
  3. A copy of your current curriculum vitae.
  4. Any other information which may be of relevance to the Membership Committee.
  5. 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

Last updated March 10, 2006

Application deadline is August 15

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