Application for Membership

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:

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