AAS Member Application - Association for Academic Surgery (AAS)

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Are you an existing AAS member looking to upgrade your member type?*

Yes

To upgrade your membership, please contact Member Services at membership@aasurg.org.

Are you a current faculty member at your institution?*

Yes

Do you currently practice/reside within the United States?*

Yes

Select the date of your first faculty position as a non-trainee.*

If you do not recall the exact date, please use your best estimate.

MM slash DD slash YYYY

Are you Active-Duty US Military?*

Yes

Please select your current country of practice/residence.*

You Qualify for Senior Membership*

Please check the box to continue

Senior Member

Are you currently a resident?*

Yes

Are you a Chief Resident or Fellow?*

Yes

Please select the one that best applies*

I am in medical school.

I am not a surgeon or faculty member, but participate in surgical research. Or, I support another of the academic missions (e.g., education) of a Department of Surgery.

I am in a Fellowship.

Would you like to be considered for Active or Candidate Membership?*

Active

Candidate

Your Membership Category*

About You

Applicant Name*

First Middle Last Suffix

Degrees (MD, FACS, PhD, etc.)

Gender*

Male

Female

I choose not to disclose

Ethnic Background*

African American/African

Asian

Caucasian

Hispanic

Not Listed

Multiracial

I choose not to disclose

Date of Birth*

MM slash DD slash YYYY

Primary Email Address*

Secondary Email Address*

Professional and Academic Contact Information

Title / Position*

Institution / Company

Department / Division

Department Chair Name

First Middle Last

Department Chair Email

Work / Primary Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work / Main Phone*

Work Fax

Website

Home / Personal Contact Information

Home / Secondary Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone*

Please use my personal address for AAS correspondence.*

Yes

Education and Training

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Undergraduate Degree

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Undergraduate Institution*

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Undergraduate Degree*

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Undergraduate Degree Year*

Medical School

Medical School Degree

Medical School Degree Year

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Internship

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Internship Institution

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Internship Degree

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Internship Year

Residency

Residency Institution

Residency End Year

If in progress, please enter the anticipated year of completion.

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Residency Degree

Fellowship

Fellowship Institution

Fellowship End Year

If in progress, please enter the anticipated year of completion.

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Fellowship Degree

Specialty

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What is the year you first held a faculty position?*

If you are a Medical Student or Candidate applicant, you may estimate or choose your member type in the drop down.

Specialty*

General Surgery

Anesthesiology

Cardiac/Thoracic Surgery

Laparoscopic Surgery

Neurosurgery

Orthopedics

Pediatric Surgery

Ophthalmology

Otorhinolaryngology

Pathology

Plastic / Reconstructive Surgery

Surgical Oncology

Thoracic Surgery

Transplantation

Trauma / Critical Care

Vascular Surgery

Urology

Colon and Rectal Surgery

Endocrine Surgery

Ear / Nose / Throat

Medical Student (n/a)

Academic Qualifications

Academic Honors

Present Positions

Institutional Positions

Area(s) of Investigative Research:

Area(s) of Clinical Interest:

Surgical and Medical Society Memberships and Roles

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Fellowship of the American College of Surgeons

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FACS Year*

If you are a Medical Student, Candidate, or Affiliate applicant, you may estimate or choose your member type in the drop down.

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FACS Type

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Royal College of Surgeons

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Royal College of Surgeons Year

If you are a Medical Student, Candidate, or Affiliate applicant, you may estimate or choose your member type in the drop down.

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Board Certification

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Board Certificate Number

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Board Certification Year

If you are a Medical Student applicant, you may estimate or choose your member type in the drop down.

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Brief Essay

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Brief Essay*

Please explain why it's important for you to become a member of the Association for Academic Surgery (50 words or less.)

Referral Information

How did you hear about the AAS?*

AAS Meeting

Advertisement in the JSR

My Program Chair

My AAS Institutional Representative

Colleague

AAS Web Site

AAS Mailing

AAS Membership Brochure

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Other

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Who can we thank for encouraging you to apply?

Referrer's Email Address

Promo Code

Medical Student Application Fee*

Price:

Candidate Application Fee*

Price:

Application Fee

Credit Card*

American Express

Discover

MasterCard

Visa

Supported Credit Cards: American Express, Discover, MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

About You

Professional and Academic Contact Information

Home / Personal Contact Information

Education and Training

Undergraduate Degree

Medical School

Internship

Residency

Fellowship

Specialty

Academic Qualifications

Fellowship of the American College of Surgeons

Royal College of Surgeons

Board Certification

Brief Essay

Referral Information

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