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SURGICAL SOCIETY APPLICATIONS

The Frederick A. Coller Surgical Society is a fellowship of surgeons whose training has been influenced by the legacy and principles of Dr. Coller, a pioneer in the history of academic surgery. It was established in 1947 by his loving and grateful former residents to honor him and further the principles which he embodied.

Applications

2022

Active Membership

Application CLOSED

Active membership is for attending physicians seeing membership with the Coller Surgical Society. For full eligibility and criteria, please see the Constitution and Bylaws.

2022

Associate Membership

Application CLOSED

Associate membership is for resident physicians seeking membership with the Coller Surgical Society. Associate members may attend the annual meeting, but will not pay dues. For full eligibility and criteria, please see the Constitution and Bylaws.

2022

Coller Traveling Fellowship

Application CLOSED

The intent and spirit of the Coller Traveling Fellowship is to provide resources to defray the costs (partially or entirely) of a clinical experience whereby (through the assistance and connections of your Coller Society member sponsor) you travel to another center and gain clinical experience through, for example, observing multidisciplinary clinics or procedures or interacting with leaders in your field. Stipend is reimbursement of travel expenses up to $2000.

2022

Surgical Research Fellowship

Application CLOSED

Research Fellowships are intended to promote the conduct of a specified research project by supporting the goods or services consumed in the acquisition of data.

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Help us perpetuate Dr. Coller's ideals through our programs, friendship, and mutual support.

FREDERICK A. COLLER SURGICAL SOCIETY

APPLICATION FOR ASSOCIATE MEMBERSHIP

TO THE COUNCIL OF THE FREDERICK A. COLLER SURGICAL SOCIETY

I hereby make Application for Associate Membership in the Frederick A. Coller Surgical Society.

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Date and Place of Birth

Are you a citizen of the United States of America or Canada?

Yes

If a Naturalized Citizen, state where and when you were Naturalized

Coller Society Sponsor Member Name

I SUBMIT THE FOLLOWING DATA CONCERNING MY MEDICAL EDUCATION AND SURGICAL TRAINING

Premedical education

University or College

Month/Year

Degree

Medical education

University or College

Month/Year

Degree

Training following Internship

Residency

Month/Year

Fellowship

Month/Year

Association with a Member of this Society?

1. With whom?

2. When?

3. How affiliated?

Other Professional Experience such as Basic Science, Private Practice, Investigative Work and Any Special Awards:

Present Hospital Staff Appointments:

Present Medical School Appointments:

Practice Limited to:

Medical and Surgical Society Memberships:

Contributions to Medical and Surgical Literature (List those Publications which have appeared to have been accepted for publication in National and State Journals. Give name of Journal and date of publication):

If application is accepted, enter name to appear on certificate below:

Please attach Curriculum Vitae (PDF format only)

Choose File

Please include sponsorship letter from a Coller Society Member (PDF format only)

Choose File

Applicant Signature

Date of Application

FREDERICK A. COLLER SURGICAL SOCIETY

APPLICATION FOR RESEARCH FELLOWSHIP

Research Fellowships are intended to promote the conduct of a specified research project by supporting the goods or services consumed in the acquisition of data. See below for a list of allowed and unallowed expenses:

Publication expenses allowed.
Payment for consumables such as animals, reagents, lab supplies, database acquisition or database use fees all permitted. Detailed budget required to validate the nature, amount and price of consumables to assure expenditures are reasonable for what is purchased and that the materiel is applicable to the project which has been approved.
Salary of technical help or fees for technical work done in cores permitted. Budget required.
Fees for work done within scientific cores (ie DNA sequencing, flow cytometry, electron microscopy etc.) permitted. Budget required.
Travel to professional meetings for presentation of results permitted if the Coller scholar is first author on work being presented. No travel outside of US permitted. No travel expenses permitted if Coller scholar not first author.
Payment of resident salary expenses, direct salary or benefits, would not be permitted.
Payment of facility rent not permitted.
Payment of indirect costs not permitted.
Educational or surgical aids that will become the property of the scholar (textbooks, subscriptions, computers, laptops, tablets, loupes, etc.) not permitted.

TO THE COUNCIL OF THE FREDERICK A. COLLER SURGICAL SOCIETY

I hereby make application for a Frederick A. Coller Surgical Research Fellowship.

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Date and Place of Birth

Are you a citizen of the United States of America or Canada?

Yes

If a Naturalized Citizen, state where and when you were Naturalized

Coller Society Sponsor Member Name

I SUBMIT THE FOLLOWING DATA CONCERNING MY MEDICAL EDUCATION AND SURGICAL TRAINING

Premedical education

University or College

Month/Year

Degree

Medical education

University or College

Month/Year

Degree

Training following Internship

Residency

Month/Year

Fellowship

Month/Year

Research Experience

Other Professional Experience

Please attach your Bibliography (PDF format only)

Choose File

Please attach your research project description for the Research Fellowship year (PDF format only)

Choose File

Download the following form and attach below with your on-site sponsor signature.

On Site Sponsor Form

Please attach your on-site sponsor form

Choose File

Please include sponsorship letter from a Coller Society Member

Choose File

Applicant Signature

Date of Application

FREDERICK A. COLLER SURGICAL SOCIETY

APPLICATION FOR TRAVELING FELLOWSHIP FOR SURGICAL RESIDENTS

The intent and spirit of the Coller Traveling Fellowship is to provide resources to defray the costs (partially or entirely) of a clinical experience whereby (through the assistance and connections of your Coller Society member sponsor) you travel to another center and gain clinical experience through, for example, observing multidisciplinary clinics or procedures or interacting with leaders in your field. The stipend is reimbursement of travel expenses up to $2000.

TO THE COUNCIL OF THE FREDERICK A. COLLER SURGICAL SOCIETY

I hereby make application for a Frederick A. Coller Traveling Fellowship.

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Date and Place of Birth

Are you a citizen of the United States of America or Canada?

Yes

If a Naturalized Citizen, state where and when you were Naturalized

Coller Society Sponsor Member Name

I SUBMIT THE FOLLOWING DATA CONCERNING MY MEDICAL EDUCATION AND SURGICAL TRAINING

Premedical education

University or College

Month/Year

Degree

Medical education

University or College

Month/Year

Degree

Training Following Internship

1. Residency or Fellowship

Residency

Month/Year

Fellowship

Month/Year

2. When will you complete your Surgical Training?

3. If approved, at what time will you take the Traveling Fellowship?

Other Professional Experience such as Basic Science, Private Practice, Investigative Work and Any Special Awards:

Please attach Bibliography (PDF format only)

Choose File

Please include sponsorship letter from a Coller Society Member (PDF format only)

Choose File

Applicant Signature

Date of Application

FREDERICK A. COLLER SURGICAL SOCIETY

APPLICATION FOR MEMBERSHIP

Active membership is for attending physicians seeking membership with the Coller Surgical Society. For full eligibility and criteria, please see the Constitution and Bylaws.

TO THE COUNCIL OF THE FREDERICK A. COLLER SURGICAL SOCIETY

I hereby make Application for Active Membership in the Frederick A. Coller Surgical Society.

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Date and Place of Birth

Are you a citizen of the United States of America or Canada?

Yes

If a Naturalized Citizen, state where and when you were Naturalized

Coller Society Sponsor Member Name

I SUBMIT THE FOLLOWING DATA CONCERNING MY MEDICAL EDUCATION AND SURGICAL TRAINING

Premedical education

University or College

Month/Year

Degree

Medical education

University or College

Month/Year

Degree

Training following Internship

Residency

Month/Year

Fellowship

Month/Year

Association with a Member of this Society?

1. With whom?

2. When?

3. How affiliated?

Other Professional Experience such as Basic Science, Private Practice, Investigative Work and Any Special Awards

Present Hospital Staff Appointments:

Present Medical School Appointments:

Practice Limited to:

Medical and Surgical Society Memberships:

If application is accepted, enter name to appear on certificate below:

Please attach Curriculum Vitae (PDF format only)

Choose File

Please include sponsorship letter from a Coller Society Member (PDF format only)

Choose File

Applicant Signature

Date of Application