AAS Member Application

All Members

All members are invited to participate actively in all of the Association's functions by submitting abstracts for scientific presentation, attending the Annual Meetings, and discussing papers presented at meetings in their area of interest. Members also receive a semi-annual Newsletter describing activities of the Association, as well as additional information on other pertinent issues before the Association and surgery.

Membership Information:

Membership Type:

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
Other Association Meeting, Journal Advertisements, and Websites -- please list them below

Referral Information

Who can we thank for encouraging you to apply?
That person's email:

About You:

First Name:
Middle Name:
Last Name:
Suffix (Jr, III, etc):
Degree(s):
Gender	Male Female
Date of Birth:	(format as: MM-DD-YYYY)

Professional and Academic Information:

Position / Title:
Institution / Company:
Department / Division:
Specialty:

Address 1:
Address 2:
City:
State/Province:
Zip/Postal Code:
Country:
Telephone:
Fax:
Email:
Website URL:

Home and Personal Information:

Address 1:
Address 2:
City:
State/Province:
Zip/Postal Code:
Country
Telephone:
Fax:
Personal Email:
Use Home/Personal Information for my AAS correspondence ―YES:

Education & Training


Institution	Degree	Year (YYYY)
UnderGraduate:
Medical School:
Institution	From (YYYY)	To (YYYY)
Internship:
Residency:
Fellowship:

Chief Resident Year:
Year of First Faculty Position:

Departmental Information

Department Chair Name:
Department Chair Email:

Academic Qualifications:

Academic Honors:
Present Positions:
Past Institutional Positions:
Area(s) of Investigative Research:
Area(s) of Clinical Interest:

Fellowship of the American College of Surgeons:

Year:

(YYYY)

Type:

Royal College of Surgeons

Year:

(YYYY)

Board Certification

Board Certification No.:		Year:	(YYYY)
Surgical & Medical Society Memberships and Roles:

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Application Deadline is: June 15, 2013

AAS CONSTITUTION