Southeastern Surgical Congress Membership Application

Southeastern Surgical Congress

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.

Check one:

Regular

Associate

Affiliate

Resident

Name:
	(First)	(Middle)	(Last)

Primary Address:

Professional Address:

City

State

Zip

Telephone No.

Fax No.

e-mail

Residential Address:

City

State

Zip

Telephone No.

Fax No.

e-mail

BIRTH DATE (01/01/2005) 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

Sub-Specialty Date

Sub-Specialty Date

MEMBERSHIP IN MEDICAL AND SURGICAL ORGANIZATIONS (please list):

HOSPITAL AND TEACHING AFFILIATIONS:

BIBLIOGRAPHY (e-mail additional pages if necessary or send CV to sesc@sesc.org):

REFERENCES (Letters not required):

Name Phone Number Address

Name Phone Number Address

Name Phone Number Address

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.

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