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SEATTLE SURGICAL SOCIETY MEMBERSHIP APPLICATION
Fill in the information below to join the Seattle Surgical Society.
First Name
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Last Name
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Degree (if applicable)
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MD
PhD
PA
NP
Other
Other
Institution
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Address 1
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Address 2
City
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State
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Postal Code
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This address is my:
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Office
Home
Cell Phone
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Fax
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Email Address
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Receiving text
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Requesting permission to send a text for dues reminders and updates.
Please contact me via email about meeting information and announcements.
Membership Category
Please indicate the category of membership you are applying.
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Active Member
Allied Member (Advanced Practice Provider)
APP Education
Education
0/255 characters
Education/Certification
Surgical Specialty
Date of graduation from medical school
Date of commencing practice in Western Washington
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Date of Fellowship, American College of Surgeons
Qualified for American College of Surgeons (fill in date if not a Fellow already )
Certification, American Board of
Date
Qualified for American Board of Surgery
Date
APPLICANT MUST BE RECOMMENDED BY 1 CURRENT FELLOW OF THE SOCIETY
Your sponsor will be contacted for verification. Please make sure they are aware that you are applying for membership to the Seattle Surgical Society.
Name of Member
*
Email
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Please attach a copy of your Curriculum Vitae
For more information,please contact our Membership Chair:
Andre Dick, MD
Email: andre.dick@seattlechildrens.org
You may also contact the Seattle Surgical Society office at 206-794-9124 or send an email to admin@seattlesurgical.org.
Seattle Surgical Society| PO Box 2459 | Lynnwood, WA 98036