Fillable Residents and Fellows Forum Membership Application Information

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Residents and Fellows Forum Membership Application Information

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2020/02
Residents and Fellows Forum Membership Application Information
Residents and Fellows represent the future of plastic surgery. At ASPS, we believe it is our mission to
support you at every stage of your career – from
residency to retirement
.
ASPS offers plastic surgery Residents and Fellows outstanding resources to assist and facilitate your
education and training, as well as tools to help launch your career.
You are invited to join the ASPS Residents and Fellows Forum for only $100 per year.
Enrollment Requirements:
•
Residents actively engaged in an accredited plastic surgery residency program in the U.S. or Canada
•
Fellows actively engaged in an ACGME accredited or private fellowship in the U.S. or Canada
As part of the ASPS Residents and Fellows Forum, you will receive the following educational benefits:
• Subscription to Plastic and Reconstructive Surgery® (PRS), the top-ranked plastic surgery journal in the world
• Subscription to Plastic Surgery News® (PSN), the most-read news publication of the specialty
• Access to the online ASPS Education Network (ASPS EdNet)
• Discounts on ASPS products and meetings, including FREE early-bird registration to Plastic Surgery The Meeting
•
Dedicated Residents section on the members-only message board
•
Access to the ASPS Job Opportunity Board and on-site interviews
•
Access to information on The PSF grants and scholarship programs
ASPS core values embody excellence in plastic surgery through education, research, intellectual exchange
and promoting unity in the specialty of plastic surgery. We believe in supporting the newest members of our
specialty and assist in your career development.
No other specialty organization offers the indispensable features and benefits that ASPS provides its
members, residents and fellows. We sincerely hope that you will join us.
ASPS…Your essential partner in the practice of plastic surgery.
sm
2020/02
Residents and Fellows Forum Membership Application
_ _ _
FIRST NAME
MIDDLE INITIAL
LAST NAME DATE
MAILING ADDRESS
_ _
CITY
STATE
ZIP CODE
TE
LEPHONE CELL PHONE EMAIL
Gend
er: ____ Male ____ Female
DAT
E OF BIRTH: _____________________________
Name of University Medical School:
Training Program Name:
________________________________________________________________________________________
Program Address
________________________________________________________________________________________
Program Address Line 2
__________
_______________ __________________ _____________________ _____________
City State/ Province Country Postal Code
Program Director:
Program Phone: Email:
_____________________________ _________________________
Month/Year Began Month/Year Ends
DATE
SIGNATURE – TRAINING PROGRAM DIRECTOR
To be signed by your Training Program Director:
I certify that the above named resident is enrolled in a plastic surgery training program during the indicated time frame.
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2020/02
Subscriptions are valid for one year and are renewable annually or until end of Residency or Fellowship training.
Authorization to Release Information
While an Applicant for Membership and if elected to membership in the American Society of Plastic Surgeons®
(ASPS or the “Society”), I agree to 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.
In furtherance of my application for membership in ASPS, I hereby request and authorize any hospital, any medical
staff, any medical organization and any person who may have information (including
medical records, patient records and reports of committees) that they deem relevant to my fitness for
membership to provide such information to the Society. I further authorize the Society to provide any information
it receives in connection with my application for membership in the Society to a state or county licensing
authority, a state or county medical association, or an accrediting body provided I have authorized the licensing
authority, medical association, or accrediting body to obtain such information.
The Society shall not be liable for acts performed in connection with the collection, evaluation, or
dissemination of information or opinions, whether or not requested or solicited, in connection with
my application for membership in the Society. I shall not 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:
Please submit application to:
ASPS Member Services
American Society of Plastic Surgeons 444 E. Algonquin Road
Arlington Heights, IL 60005-4664
Or email to: membership@plasticsurgery.org
Or fax to: +001 847-228-7099
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Residents and Fellows Forum Membership Application Information

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Completed 26 April 2021

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