curve
About You:
First Name:
Middle Name:
Last Name:
Suffix (Jr, III, etc):
Degree(s):
Birthday: (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:
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:
Year of First Faculty Position:

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:

Membership Information:
Membership Type:
Chief Resident Year: (Candidates Only, YYYY)

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

Departmental Information
Department Chair Name:
Department Chair Email:

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

Application Deadline are as follows:

  • Applicant Deadline for January review: December 15th
  • Applicant Deadline for April review: March 15th
  • Applicant Deadline for July review: June 15th
  • Applicant Deadline for October review: September 15th