SEATTLE SURGICAL SOCIETY MEMBERSHIP APPLICATION

CONSTITUTION AND BYLAWS OF THE SEATTLE SURGICAL SOCIETY ARTICLE XIV

Qualifications:

Section 1 – Membership shall be by invitation only.

Section 2 – A minimum of six years shall have elapsed from candidate’s graduation from medical school.

Section 3 – A Candidate’s professional credentials shall be at least equivalent to the existing qualifications for election to the American College of Surgeons; or the candidate has completed surgical residency training in Washington State.

Fill in the information below to join the Seattle Surgical Society.

* First Name

* Last Name

* Degree (if applicable)

PhD

Other

* Institution

* Address 1

Address 2

* City

* State

* Postal Code

* This address is my:

Office

Home

* Phone

* Fax

* Email Address

* Contact me via email with meeting information and announcements.

Yes

Education/Certification

* Date of graduation from medical school

* Date of commencing practice in Western Washington

* Date of Fellowship, American College of Surgeons

* Certification, American Board of

Date

Qualified for American College of Surgeons (fill in date if not a Fellow already )

Qualified for American Board of Surgery

Date

APPLICANT MUST BE RECOMMENDED BY 2 CURRENT FELLOWS OF THE SOCIETY

* Name of Member

* Email

* Name of Member

* Email

Please attach a copy of your Curriculum Vitae

For more information, please contact our Membership Chair:

Kaj Johansen, MD
1600 E. Jefferson #501
Seattle, WA 98122

Email: kaj.johansen@swedish.org

You may also contact the Seattle Surgical Society office at 425-354-3230 or send an email to seattlesurg@gmail.com.

* Indicates Response Required