Midwest Surgical Association

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Online Membership Application Submission Form

INSTRUCTIONS

Please fill out this form completely.
You will need to send a copy of your board certificate to the office of the secretary.
Two active members of Midwest Surgical Association must provide letters of recommendation on your behalf. They will send the letters directly to the office of the secretary.
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.
Deadline: To be considered for membership in the current year, your completed application packet must be in the office of the secretary by the last week of July. The application will be presented to the Executive Council meeting in August.

US mail submission:
Roxie M. Albrecht, MD
Secretary, Midwest Surgical Association
Oklahoma University Health Sciences Center
920 Stanton L. Young Blvd WP 2140
Oklahoma City, OK 73104

Facsimile submission: (405) 271-3919

For more information contact:
Linda-Gentry@ouhsc.edu

* indicates required field

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

Home Address
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

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
Please list two sponsors (names and addresses) who are members of the Midwest Surgical Association. Letters of recommendation must be sent to the MSA secretary.
* Sponsor 1
* Sponsor 2
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
* What is 4 + 5? (This is to ensure the form is being submitted by a person, not an automated spamming script.)

Midwest Surgical Association - 1101 24th Street - West Des Moines, Iowa 50266 - Phone: 515.274.4339