Date of Birth: mm/dd/yyyy
Current Academic and Affiliation Title
City State Zip Country
Phone Fax E-mail
City State Zip Country
Preferred Mailing Address Office AddressHome Address
Institution Granting Medical Degree Year
Site of Residency Training in Thoracic Surgery Dates
Actual or Anticipated Start of Practice (month/year)
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
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
Other Surgical Societies
Percentage of Practice Devoted to Cardiothoracic Surgery %
Percentage of Practice Devoted to the following Subspecialties:
Adult Cardiac % General Thoracic %
Congenital % Vascular % Other %
Practice Setting: AcademicHospitalPrivateOther (please explain) Other:
1. State(s), Province(s), and 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 attach to application) YesNoN/A
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 Have you ever had your license/certification or any right associated with the practice of medicine restricted, rescinded or placed on probation through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 attach to application) YesNoN/A
3. Current Hospital Staff Appointments:
4. Has any hospital ever denied your request for any type of surgical privilege? (if yes, please attach to application)
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 attach to application)
6. Has any hospital ever imposed supervision or compulsory consultation, or is any attempt to do so now in progress? (if yes, please attach to application)
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.
By clicking this button, I agree to and confirm the above Application Terms and Conditions.
To submit this application, please click on the "I agree" button above and click the "Submit Application" button below.
Please attach your curriculum vitae and any additional documents here. (25 megabyte limit)
E-mail: firstname.lastname@example.org • Phone: (312) 202-5800 • Fax: (312) 268-7490