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Midwest Surgical Association
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  Online ACTIVE Membership Application Submission Form
 
 

INSTRUCTIONS

  1. This form is for ACTIVE member applicants only. Please fill out this form completely.
    (If you are interested in an ASSOCIATE membership, please view the associate membership application.)
  2. You will need to send a copy of your board certificate to the office of the secretary.
  3. Two active members of Midwest Surgical Association must provide letters of recommendation on your behalf. You must attach electronic copies below.
  4. To acknowledge that you agree to honor the pledge of the Association, be sure to type your name and the date in the boxes provided at the end of this form.
  5. Deadline: To be considered for membership in the current year, you must submit the form below by July 31st. The application will be presented to the Executive Council meeting in August.

For more information contact:
info@midwestsurg.org

   * indicates required field

CONTACT INFORMATION
* Name     
First, Middle, Last
Institution
Institution Name
* Address (Line 1)
Address (Line 2)
* City, State, Zip Code
* Phone    Fax   
* E-mail
Home
Street
City, State, Zip Code
Home Phone    Home E-mail  


PERSONAL INFORMATION
* Date of Birth   * Place of Birth  
* Citizenship    Visa Status   
Marital Status    Spouse's Name   
Gender    Number of Children   
Hobbies


CURRICULUM VITAE
Upload CV


EXPERIENCE
List in chronological order, include position details, dates.
* History
* Academic Positions
* Hospital Appointments


EDUCATION
Include school, location, years attended, graduation date, degree.
* Under-Graduate School
* Graduate School
* Medical School
Fellowship Training
Post-Doctoral Training


PROFESSIONAL QUALIFICATIONS
* Certifications and Accreditations
Please send a copy of your specialty board certificate to the MSA secretary.
* Professional Memberships
* Publications
* Awards


SPONSORS
Please list two sponsors (names and addresses) who are members of the Midwest Surgical Association, and upload letters of recommendation from each.
* Sponsor 1
Name & Address
* Upload Sponsor 1 Letter
* Sponsor 2
Name & Address
* Upload Sponsor 2 Letter


PLEDGE
Upon being accepted into the Midwest Surgical Association, I hereby declare that my practice of medicine conforms to the highest ethical standards. I will strive to help other surgeons of like mind to control all unethical practices. I will always work for the elevation and improvement of the standards of surgical practice.
* Name of Applicant
Filling in this field indicates you accept the above pledge
* Date

 

  
 
Midwest Surgical Association - 5019 W. 147th Street - Leawood, Kansas 66224 - Phone: 913.402.7102
  
   
 

 

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