Individual Member Application Form

Individual Membership Application Form

Member Application form for Faculty, Residents, Medical Students, Advanced Practice Providers and Registered Nurses.

Applicant Name(Required)

First Middle Last Degree (ex. MD, DO)

Additional Degree(s) other than MD/DO. please check all that apply:(Required)

If Additional Degree is Other, please specify:(Required)

Membership Category to which you are applying:(Required)

Faculty/Attending

Resident/Fellow

Medical Student

Advanced Practice Provider (APP)/Registered Nurse (RN)

Current Academic Rank(Required)

If Academic Rank is Other, please specify:(Required)

Academic Leadership Position(s)(Required)

Use this space to list your positions at your institution (i.e. Chair, Clerkship Director, Program Director, Division Chair, etc.)

Current Institution(Required)

Specialty(Required)

Check all that apply:

If Specialty is Other, please specify:(Required)

Preferred Mailing Address

Address Type(Required)

Current Institution/Office

Home

Other

Address Line 1(Required)

Address Line 2

City(Required)

State/Province(Required)

Zip / Postal Code

Country(Required)

Preferred Contacts

Cell Phone(Required)

Office Phone(Required)

Preferred Email Address(Required)

We strongly recommend creating/using a non-institution email address (e.g. Gmail) for society business.

Alternate Email Address:(Required)

In case we can’t reach you at the primary email address.

Assistant First and Last Name

Assistant Email Address

Other Information

Gender(Required)

Male

Female

Non binary

Prefer not to specify

Date of Birth(Required)

Fellow of the American College of Surgeons (FACS)(Required)

Yes

Are you certified by the ABMS?(Required)

Yes

Certification Focus(Required)

Use this space to identify the focus of your board certification (i.e.. General, Colorectal, Vascular, etc.). Please list all specialties and subspecialties and the year of certification, for example General Surgery, 2013. If you have multiple certifications, use the + icon to add additional row.

Certification Specialty

Year of Certification

Do you have an active medical licence?(Required)

Yes

In which state(s)?(Required)

Educational Background

Undergraduate School Name

Undergraduate Degree

Medical School(Required)

Year Completed/Will Complete(Required)

Medical School Honor Societies (if applicable)

Alpha Omega Alpha

Gold Humanism Society

Internship Training Program

Internship Training Concentration

Year Completed/Will Complete

Residency Training Program(Required)

Use this space to identify your residency program (i.e. Emory University)

Residency Training Concentration(Required)

Use this space to identify your residency training focus (i.e. MIS, Plastics, Pediatrics, etc.)

Year Completed/Will Complete(Required)

Are you enrolled in or have you completed a fellowship?(Required)

Yes

Fellowship Training Program(Required)

Use this space to identify the program where you completed your fellowship. (i.e. University of Washington)

Fellowship Training Concentration(Required)

Use this space to identify your fellowship training focus (i.e. MIS, Plastics, Pediatrics, etc.)

Year Completed/Will Complete(Required)

Letter(s) of Recommendation, Professional Experience and Academic Interests

Chairperson's Name(Required)

First Last

Reference Letter from Chairperson (.pdf)(Required)

Accepted file types: pdf, Max. file size: 10 MB.

Faculty Member's Name(Required)

First Last

Reference Letter from Faculty Member (.pdf)(Required)

Max. file size: 10 MB.

Professional Experience and Expertise(Required)

Briefly describe your current role and primary responsibilities in the surgical field.
Highlight key surgical, research, educational, or clinical accomplishments that reflect your expertise and professional growth.
Please include any leadership roles you have held in academic, clinical, or professional settings.
If you have been involved in surgical societies or medical organizations, list them and describe your roles and contributions.

Please avoid repeating information already included in your CV; concise narrative summaries are preferred.

Please select your areas of Academic Interest from the list below. You may select up to 3 areas.(Required)

View the categories comprising each area of Academic Interest.

RESEARCH AND DISCOVERY

EDUCATION AND TRAINING

QUALITY, SAFETY & SYSTEMS IMPROVEMENT

CLINICAL SCHOLARSHIP & PRACTICE INNOVATION

LEADERSHIP, POLICY AND PROFESSIONAL DEVELOPMENT

COMMUNITY ENGAGEMENT & PUBLIC HEALTH

OTHER

Research and Academic Contributions and Interests(Required)

What are your specific research and academic contributions and interests?
Indicate whether you are interested in participating in SBAS-led research initiatives or collaborative studies.

Would be willing to mentor medical students, residents, or fellows in research or scholarly activities?(Required)

Yes

Interest in SBAS Engagement and Activities(Required)

Describe the aspects of SBAS activities that most interest you (e.g., educational workshops, research collaborations, mentorship, leadership development).
Indicate your willingness to volunteer for committees or leadership roles within SBAS.
If applicable, briefly describe any ideas or initiatives you would like to propose to support the mission of the Society.

Future Individual Goals and Aspirations(Required)

Outline your professional goals for the next 5–10 years and describe how involvement in SBAS aligns with and supports those goals.
Please discuss the impact you hope to have in surgery, academic medicine, leadership, or mentorship through your engagement with SBAS.

Please upload a current headshot(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, avif, Max. file size: 512 MB, Max. files: 1.

Please upload current CV (.pdf)(Required)

Accepted file types: pdf, Max. file size: 512 MB.

Other Society Memberships

Surgical Society Memberships(Required)

Check all that apply:

If Surgical Society Membership is Other, please specify:(Required)

Surgical Subspecialty Societies(Required)

Check all that apply:

If Surgical Subspecialty Society is Other, please specify:(Required)

Payment Information

Faculty/Attending Application Fee

Price:

Promo Code

Total

Credit Card(Required)

Individual Membership Application Form

Preferred Mailing Address

Preferred Contacts

Other Information

Educational Background

Letter(s) of Recommendation, Professional Experience and Academic Interests

Other Society Memberships

Payment Information

Confirm Submission