Application for Membership



Check One:

First Name Last Name MI Degree

Date of Birth: mm/dd/yyyy

Gender:

Current Academic and Affiliation Title

Current Institution

Office Address

                        

                 City State Zip Country

               Phone Fax Email

Home Address

               City State Zip Country

Preferred Mailing Address

EDUCATION

Institution Granting Medical Degree Year

Site of Resident Training in Thoracic Surgery Dates

Actual or Anticipated Start of Practice (month/year)

CERTIFICATION

American Board of Surgery                    Certificate No. Year

American Board of Thoracic Surgery      Certificate No. Year

American Osteopathic Board of              Certificate No. Year
Cardiovascular & Thoracic Surgery

Royal College of Surgeons of Canada     Certificate No. Year

Other Board Certification as Applicable

Certifying Body Certificate No. Year

Certifying Body Certificate No. Year

MEMBERSHIPS

Fellowship, American College of Surgeons                      Member No.

Asian Society for Cardiovascular and Thoracic Surgery   Member No.

European Society of Thoracic Surgeons                          Member No.

European Association for Cardio-Thoracic Surgery        Member No. Year

Member in Other Surgical Societies             

PRACTICE

Percentage of Practice Devoted to Cardiothoracic Surgery %

Percentage of Practice Devoted to the following Subspecialties:

Adult Cardiac %    General Thoracic %    Congenital %    Vascular %    Other %

Practice Setting: Other:

SPONSOR (NOTE: Sponsor must be an STS Active or International Member. STS will contact your sponsor to confirm that you are qualified for the membership category for which you are applying.)

Name: Address:

Phone: Email:

Additional Applicant Information

1. State(s), Province(s), or Country(ies) in which Licensed/Certified to Practice Medicine:

License/Certification Number(s): Date(s) Originally issued:

Are there any current restrictions on this license/certification? (if yes, please submit details via email or fax)

2. Have you ever had your license/certification or any right associated with the practice of medicine restricted, rescinded or placed on probation through governmental action or voluntary surrender, or is any process now pending that could yield such a result? (if yes, please submit details via email or fax)

3. Current Hospital Staff Appointments:

4. Has any hospital ever denied your request for any type of surgical privilege? (if yes, please submit details via email or fax)

5. Has any hospital ever reduced, restricted, suspended, terminated, or requested you to resign all or any portion of your surgical staff privileges, or is any process now pending that could yield such a result? (if yes, please submit details via email or fax)

6. Has any hospital ever imposed supervision or compulsory consultation, or is any attempt to do so now in progress? (if yes, please submit details via email or fax)

Applications Terms and Conditions

In furtherance of my application for membership in The Society of Thoracic Surgeons, I hereby request and authorize any hospital or medical staff where I now have, have had, or have applied formedical staff privileges, and any medical organization of which I am a member or to which I have applied for membership, and any person who may have information (including medical records,patient records, and reports of committees) which is deemed by the Society to be material to its evaluation of my fitness for membership to provide such information to representatives of theSociety upon their request. I agree that communications of any nature made to the Society regarding my fitness for membership shall be made in confidence and shall not be made available to meunder any circumstances. I hereby release from liability the Society and its officers, directors, members, agents and employees, and the providers of any information about me, and each of them, and agree to save and hold each of them harmless from and against all claims, costs and expenses (including reasonable attorneys' fees), demands, actions and liability arising from or relating toacts performed in good faith and without malice in connection with the provision, collection, or evaluation of information or opinions, whether or not requested or solicited, concerning myapplication for membership in the Society.

I hereby represent and warrant that the information provided on this application for membership is accurate and complete. I agree that I will not cause or attempt to cause any public disclosure ofthe contents of any application for membership in the Society, including my own, or any proceedings of any committees evaluating such applications, whether disclosure is by operation of law orotherwise. Furthermore, I agree that if I am admitted as a member of the Society, I shall abide by the Bylaws and rules of the Society.


 
To submit this application, please click on the "I agree" button above and click the "Submit Application" button below.
Date:

Please attach documents here.(25 megabyte limit)





*Application and curriculum vitae are due by October 15.
Application materials should be sent to:
Chair, Membership Committee • The Society of Thoracic Surgeons • 633 North Saint Clair Street, Suite 2320
Chicago, IL 60611 • (312) 202-5800 Phone • (312) 268-7490 Fax • membership@sts.org