AAS Member ApplicationRevised AAS Member Application 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.Step 1 of 250%Member Type*Active MemberActive InternationalCandidate MemberSenior MemberAffiliate MemberMedical StudentUpgrading to Active (from Candidate)Upgrading to Candidate (from Med Student)About YouApplicant Name* First Middle Last Suffix Degrees (MD, FACS, PhD, etc.)Gender*MaleFemaleDate of Birth* Primary Email Address* Secondary Email Address Professional and Academic Contact InformationTitle / PositionInstitution / CompanyDepartment / DivisionDepartment Chair Name First Middle Last Department Chair Email Work / Primary Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Work / Main Phone*Work FaxWebsite Home / Personal Contact InformationHome / Secondary Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Cell PhonePlease use my personal address for AAS correspondence.*YesNoEducation and TrainingUndergraduate DegreeUndergraduate Institution*Undergraduate Degree*Undergraduate Degree Year*Medical SchoolMedical SchoolMedical School DegreeMedical School Degree YearInternshipInternship InstitutionInternship DegreeInternship YearResidencyResidency InstitutionResidency DegreeResidency YearFellowshipFellowship InstitutionFellowship DegreeFellowship YearWhat 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.Medical StudentCandidate198019811982198319841985198619871988198919901991199219941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242024202520262027202820292030Specialty 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 QualificationsAcademic HonorsPresent PositionsInstitutional PositionsArea(s) of Investigative Research:Area(s) of Clinical Interest:Surgical and Medical Society Memberships and RolesFellowship of the American College of SurgeonsFACS Year*If you are a Medical Student or Candidate applicant, you may estimate or choose your member type in the drop down.Medical StudentCandidate198019811982198319841985198619871988198919901991199219941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242024202520262027202820292030FACS TypeFellowCandidateAssociate FellowRoyal College of SurgeonsRoyal College of Surgeons YearIf you are a Medical Student or Candidate applicant, you may estimate or choose your member type in the drop down.Medical StudentCandidate198019811982198319841985198619871988198919901991199219941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242024202520262027202820292030Board CertificationBoard Certificate NumberBoard Certification YearIf you are a Medical Student applicant, you may estimate or choose your member type in the drop down.Medical Student198019811982198319841985198619871988198919901991199219941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242024202520262027202820292030Brief EssayBrief Essay*Please explain why it's important for you to become a member of the Association for Academic Surgery (50 words or less.)Referral InformationHow 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 BrochureOtherWho can we thank for encouraging you to apply?Referrer's Email Address Promo Code Application Fee $0.00 Credit Card*American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name This iframe contains the logic required to handle Ajax powered Gravity Forms.