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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


Date of Birth:
(format as: MM-DD-YYYY)

Professional and Academic Contact 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 Contact 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:

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

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Application Deadline is:

 
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