AMERICAN SOCIETY FOR RECONSTRUCTIVE MICROSURGERY

Candidate Membership Application

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 not serve on committees, vote, or hold office. This category is valid for 5 years.

 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

 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
        
        
        

 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.

INSTRUCTIONS

Candidates for membership are to be proposed and sponsored by one Active or Associate member of the ASRM. The sponsor must sign the original application form if he/she agrees with the following statement: "This is to certify that the applicant is of sound moral and ethical standing. I support his candidate membership in the ASRM."

Sponsor

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. 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, Last updated August 12, 2008

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