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APPLICATION FOR FELLOWSHIP
All areas must be completed before processing can begin.
Check One: ____ Regular ____ Associate
____ Affiliate ____ Resident
Please print or type
NAME
(First)_____________________ (Middle)_____________
(Last)___________________
ADDRESS (Please fill in
professional and residence information, then check primary address to
which all official correspondence should be sent.)
____Professional_____________________________________________________________
______________________________________________________________________
City____________________________________
State________Zip _______________
Telephone No.
________________________ Fax No. __________________________
E-mail
________________________________________________________________
____Residence _____________________________________________________________
______________________________________________________________________
City_________________________________
State__________ Zip________________
Telephone
No.__________________________ Fax No. ________________________
E-mail
________________________________________________________________
Birth date _____________________ Place
____________________________
EDUCATION AND TRAINING
Undergraduate________________________________________________________________
(Institution)
(Dates Attended)
Degree (Major)
Post-graduate_________________________________________________________________
(Institution)
(Dates Attended)
Degree (Major)
Medical______________________________________________________________________
(Institution)
(Dates Attended)
Degree (Major)
Internship____________________________________________________________________
(Institution)
(Dates Attended)
Degree (Major)
Residency____________________________________________________________________
(Institution)
(Dates Attended)
Degree (Major)
Residency____________________________________________________________________
(Institution)
(Dates Attended)
Degree (Major)
Fellowship____________________________________________________________________
(Institution)
(Dates Attended)
Degree (Major)
BOARD CERTIFICATION:
Specialty _______________________________ Date ___________
MEMBERSHIP IN MEDICAL & SURGICAL
ORGANIZATIONS (please list):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
HOSPITAL AND TEACHING AFFILIATIONS:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
BIBLIOGRAPHY (add additional pages
if necessary or include CV):
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
REFERENCES (Letters not required.)
Name _________________________________________________________
Address _______________________________________________________
Phone Number __________________________________________________
Name _________________________________________________________
Address _______________________________________________________
Phone Number __________________________________________________
Name _________________________________________________________
Address _______________________________________________________
Phone Number __________________________________________________
If accepted for Fellowship, I hereby agree to abide by the Constitution
and By-Laws of the Southeastern Surgical Congress, to attend its
meetings, and contribute by the presentation of papers and entering into
discussions.
Applicant's Signature ____________________________ Date _____________
SOUTHEASTERN SURGICAL CONGRESS
CATEGORIES OF FELLOWSHIP
TYPES OF FELLOWS - Fellowships are
unlimited in number and are composed of Regular Fellows, Associate
Fellows, Affiliate Fellows, Resident Fellows, and Honorary Fellows.
REGULAR FELLOW -
A surgeon who is a diplomat of an approved surgical Board* who
resides in the territory of the Congress.
AFFILIATE FELLOW -
A surgeon who has completed an approved residency but has not passed the
respective Board exams. Dues shall be the same as for Regular Fellows.
ASSOCIATE FELLOW -
A surgeon who is a diplomat of an approved surgical board* who resides
outside the territory of the Congress.
RESIDENT FELLOW
- A resident who is in training in an approved residency program.** Dues
are minimal and include a subscription to The American Surgeon.
* Approved by the American Board of
Medical Specialties
** Approved by the Accreditation Council for Graduate Medical Education
INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR
FELLOWSHIP
1. Applications for Fellowship must include three references.
2. All information must be filled in completely.
3. Mail completed application to:
Southeastern Surgical Congress
141 West Wieuca Road
Suite B100
Atlanta, GA 30342
Applicant, do not write below this line.
Approved by State Credentials Committee
Regular Fellow: Yes ____ No ____
Affiliate Fellow: Yes ____ No ____
Associate Fellow: Yes ____ No ____
Resident Fellow: Yes ____ No ____
____________________________________
_________________
Signature of State Councilor
Date
Approved by Central Credentials Committee
_______________________________________________
Chairman Membership Committee
Member No. __________________________________
____Regular ____Affiliate ____Associate _____Resident |
