P1
AAPS
ASIAN ASSOCIATION OF PEDIATRIC SURGEONS
APPLICATION
I.
FORM FOR MEMBERSHIP
GENERAL INFORMATION
Name
(Last)
Country
Citizenship
Date of Birth
[ ] Home Address
Phone
Phone
preferable
address
Year of Graduation
SURGICAL RESIDENCY
Hospital
IV.
Location
PEDIATRIC
BOARDS,
Dates
SURGICAL RESIDENCY
Hospital
V.
for mailing
EDUCATION
Medical School
III.
(Middle)
[ ] Office Address
[ ] Please check the
II.
(First)
Location
DEGREES,
Dates
TITLES, FELLOWSHIPS, HONOURS:
Date
VI.
CATEGORY OF SPECIALTY OF PRACTICE
Pediatric Surgery (90%):
Ped Urology:
VII.
Ped Surg & General Surg:
Ped Thoracic Surg:
Specify:
CURRENT PROFESSIONAL ACTIVITIES
INSTITUTE
A.
Academic
B.
Hospital
Appointment:
Appointment:
TITLE
P2
AAPS
VIII.
IX.
OTHER PEDIATRIC SURGICAL ORGANIZATIONS OF WHICH THE
APPLICANT IS THE MEMBERSHIP
Organizations
Year of Enrollment
NAMES
A.
& ADDRESSES
OF SPONSORING MEMBERSHIPS (2)
Name:
Address:
B.
Name:
Address:
I HEREBY CERTIFY THAT I AM A MEMBER IN GOOD STANDING
OF THE ASIAN ASSOCIATION OF PEDIATRIC SURGEONS AND THAT
THE INFORMATION PRESENTED IN THIS FORM IS ACCURATE.
Name
Date
Name
X.
Date
SIGNATURE OF
APPLICANT:
(signature)
(Date)
Instructions to complete this form.
After filling this form, please send it to your sponsoring memberships (2)
to have their signatures. Curriculum vitae with bibliography should be
accompanied with this form. Commending letters of sponsoring members are
required.
FOR AAPS
OFFICE
USE:
APPLICATION RECEIVED BY AAPS SECRETARY
SPONSORING
LETTER
Date
RECEIVED
APPROVED BY EXECUTIVE BOARD
APPROVED BY COUNCIL
CERTIFICATE MAILED TO APPLICANT
*REGULAR MEMBERSHIP
ENROLLMENT FEE
ASSOCIATE MEMBERSHIP
DATE RECEIVED
RECEIPT#