Membership Application | Illinois Surgical Society

TO THE MEMBERSHIP COMMITTEE OF THE ILLINOIS SURGICAL SOCIETY:
I HEREBY MAKE APPLICATION FOR MEMBERSHIP IN THE ILLINOIS SURGICAL SOCIETY.
Name*
First Last
D.O.B.*
MM slash DD slash YYYY
Office Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Date of Applicaton:*
MM slash DD slash YYYY
Email*
TO THE EXECUTIVE COMMITTEE OF THE ILLINOIS SURGICAL SOCIETY:
WE VOUCH FOR THE CHARACTER AND STANDING OF THIS APPLICANT AND RECOMMEND ELECTION FOR ACTIVE MEMBERSHIP.
SPONSORED BY*
First Name Last Name Signature
ENDORSED BY (1)*
First Name Last Name Signature
ENDORSED BY (2)*
First Name Last Name Signature

TO THE EXECUTIVE COMMITTEE OF THE ILLINOIS SURGICAL SOCIETY:
FOR YOUR REVIEW I SUBMIT THE FOLLOWING INFORMATION CONCERNING MY MEDICAL EDUCATION AND SURGICAL EXPERIENCE:
1. PREMEDICAL EDUCATION:
Date Degree University Name
2. MEDICAL EDUCATION
Date Degree University Name
3. INTERNSHIP
Start Date End Date Hospital
4. SURGICAL RESIDENCY AND/OR FELLOWSHIP (HOPSITAL DATES AND POSITION IN HOSPITAL)
Start Date End Date Hospital Position
5. SURGICAL EXPERIENCE, RESEARCH WORK AND OTHER POSTGRADUATE WORK IN ADDITION TO SURGICAL FELLOWSHIP OR RESIDENCY; AS ASSISTANT OR ASSOCIATE WITH A SURGEON; IN MEDICAL SCHOOL AND DISPENSARIES; IN EXPERIMENTAL LABOARATORIES; IN CLINICS, POSTGRADUATE COURSES ETC.*
6a. PAST HOSPTIAL ASSOCIATIONS AND APPOINTMENTS (AND DATES)
Date (YYYY-MM-DD) Association / Appointment Hospital
6b. PAST MEDICAL SCHOOL ASSOCIATIONS AND APPOINTMENTS (AND DATES)
Date Association / Appointment Medical School

7a. PRESENT HOSPITAL ASSOCIATIONS AND APPOINTMENTS (AND DATES)
Date (YYYY-MM-DD) Association/Appointment Hospital
7b. PRESENT MEDICAL SCHOOL ASSOCIATIONS AND APPOINTMENTS (AND DATES)
Date Association/Appointment Medical School
8. PRACTICE/SPECIALTY
9. CERTIFICATE(S) OF AMERICAN BOARD OF SURGERY OF ALLIED SPECIALTIES
Date Certified Name of Board
10. MEMBERSHIPS IN OTHER MEDICAL AND SURGICAL SOCIETIES
11. LIST OF CHIEF CONTRIBUTIONS AND SURGICAL LITERATURE WITH DATE AND PLACE OF PUBLICATIONS
Date Place of Publication

I AGREE, IF ELECTED TO THE SOCIETY, TO ATTEND ITS MEETINGS AND CONTRIBUTE TO THE MEETINGS BY PRESENTATION OF PAPERS AND BY ENTERING INTO THE DISCUSSIONS.

_______________________________________________________________________ (SIGNATURE) __________________________________ (DATE)

Date	Degree	University Name

Date	Degree	University Name

Start Date	End Date	Hospital

Start Date	End Date	Hospital	Position