ASPS offersa oneandfellows in plastic surgery training programs and surgeons in plastic surgery apprenticeshipsAs an International Resident or Fellowyou will receive thefollowing educational benefitsE ID: 889509
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1 ��2020/0International Resi
��2020/0International Residents and Fellows Membership ApplicationInformation ASPS offersa one andfellows in plastic surgery training programs and surgeons in plastic surgery apprenticeships. As an International Resident or Fellowyou will receive thefollowing educational benefits: Electronic subscription to Electronic subscription to Plastic Surgery News® (PSN) Access to ASPS Education Network® (ASPS EdNet) Free admission to Plastic Surgery The Meetingwith registration completed prior to the end of the early bird registration deadline Access to the ASPS Job Opportunity Board and onsite interviews Access to information on The PSF grants and scholarship programs Enrollment Requirements Enrollment is for residents, fellows and trainees located outside the United States and Canadaand must meet the following requirements: training program Annual enrollment is limited to six years, if a resident is in training for 46 years Submit ASPS International Resident Subscription form Surgery Program ��2020/02 International Residents and Fellows Membership Application _______________ FIRST NAMEMI LAST NAME(FAMILYNAME)DATE OFAPPLICATION ADDRESS LINE 1 ADDRESS LINE 2 _ CITYSTATE/PROVINCECOUNTRYPOSTALCODE _ TELEPHONECELLPHONEEMAIL Gende Male Female Date ofBirth(DD/MM/YY): Name of MedicalSchool(University) Graduated/CompletedMonth/Year General Surgery (NameH
2 ospital/Institution) General SurgeryStar
ospital/Institution) General SurgeryStartMonth/Year General SurgeryEndMonth/Year_ Plastic Surgery Training Information: Choose one Plastic Surgery (residency)StartMonth/YearPlastic SurgeryEndMonth/Year FellowshipStartMonth/YearPlastic Surgery EndMonth/Year Name ofHospital/Institution_ Hospital/Institution Address Line 1 Hospital/Institution AddressLine 2 _ _ CityState/ProvinceCountryPostalCode Training Program DirectorName: Training ProgramDirectorPhone:Email: ��2020/0 Subscriptions are valid for one year and are renewable annually or until end of Residency or Fellowship training.Please submit a letter of recommendation from your training program director affirming that you are currently on the program. Authorization to Release InformationWhileApplicantforMembershipandelectedmembershiptheAmericanSocietyofPlastic Surgeons® (ASPS or the “Society”), Iagreeto abide by the Society’s Bylaws and Code of Ethics. I understand that membership in ASPS is a privilege and not a right. As an applicant for membership, I have the responsibility of providing information adequate for proper evaluation of my fitness for membership in ASPS.furtheranceofmyapplicationformembershipASPS, Iherebyrequest and authorize any hospital, any medical staff, any medical organization and any person who may have information (including medicalrecords,patientrecordsandreportsof committees) that they deem relevan
3 t to my fitness for membership toprovide
t to my fitness for membership toprovide such information to the Society. I further authorize the Society to provide any information it receives in connection with myapplication for membership in the Society to a state or county licensing authority, a state or county medical association, or an accrediting body provided I havauthorized the licensing authority, medical association, or accrediting body to obtain suchinformation.TheSocietyshallnotliableforactsperformedconnectionwiththecollection,evaluation,or disseminationofinformationoropinions,whetherornotrequestedorsolicited,connectionwith myapplicationformembershiptheSociety.shallnot demand, through any judicial process, access to any information accumulated or prepared by the Society in considering my application for membership. Name (Printed):___________________________________________________________________ Signature:Date: Pleasesubmit application and letter of recommendation from your training program director to:ASPS Member ServicesAmerican Society of Plastic Surgeons 444 E. Algonquin RoadArlington Heights, IL 600054664Or email to: membership@plasticsurgery.org Or fax to: +001 8472287099 To be signed by your Training Program/ Hospital Residency Director:I certify that the above named resident is enrolled in a plastic surgery training program during the indicated time frame. SIGNATURE – TRAINING PROGRAM / HOSPITAL RESIDENCY DIRECTOR DAT