ASSOCIATION OF VA SURGEONS MEMBERSHIP APPLICATION

Please complete the application below to join the Association of VA Surgeons. Membership dues of $200 are due upon approval and annually thereafter. Membership requires timely payment. Members are expected to attend the annual meeting.

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First Name *

Last Name *

Degree (if applicable) *

Institution *

Address 1 *

City *

State *

Postal Code *

Phone *

Fax *

Preferred Email Address *

How do you describe yourself? (Mark one answer) *

Membership Category

Active Members are surgeons, surgical specialists and anesthesiologists affiliated with the Department of Veterans Affairs who hold certification by the American Board of their specialty or Fellowship in or certification by one of the Royal or American Colleges. Only Active Members are eligible for election to office or appointment to standing committees.
Associate Members shall be individuals having an interest in patient care, medical education, or research in surgery in the Department of Veterans Affairs (including but not limited to research scientists, physician assistants, perfusionists, nurses, nurse practitioners, practice administrators, data managers and other health care professionals). Active members who are terminating affiliation with the Department of Veterans Affairs by means other than retirement may apply to the Executive Committee for Associate Member status. Associate Members shall pay dues. They shall not be entitled to hold office.

Choose the category below: *

Active Membership ($200)

Associate Membership ($200)

Current VA Teaching Appointments

Please list your current teaching appointments (include Title and Institution): *

VA Hospital *

Location *

Duration of VA Service (Years) *

Specialty *

Employment Status (check one) *

Clinical/Research Interests *

Are you interested in participating in AVAS committees?

Which AVAS committee are you interested in? *

SPONSORSHIP

APPLICANT MUST BE SPONSORED BY A CURRENT MEMBER OR SENIOR MEMBER OF THE AVAS. If there are no members of the AVAS at your hospital, please provide the name of your Chief of Staff, Chairman of the appropriate academic department, or a Fellow of the American College of Surgeons. No formal letter is required.

NOTE: We will be contacting the names you provide below for recommendation so please make sure the email address is correct and that your sponsors are aware of your application.

Name of AVAS Member or Chief of Staff *

Email *

Name of AVAS Member or Chief of Staff *

Email *

Please attach a copy of your Curriculum Vitae *

Full-Time	Part-Time
Contract Physician	Consultant Only
Other Other

Program	Research
Membership	Awards
Communications	DEI
Bylaws	Archives
Publications