2021-2022 SAGES Fellowship Certification – Application I hereby request a SAGES Certificate of MIS Fellowship TrainingFirst Name* Enter information EXACTLY as they are to appear on the certificateLast Name* Degree(s) Email* Cell Phone*Send the Certificate To* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country I am applying for SAGES Certification In* Advanced GI / MIS Flexible Endoscopy Check all that applyResidency Program and Year of Completion* Fellowship Program and Year of Completion* Type of Fellowship* Is this program accredited by the Fellowship Council* Yes No Sorry In order to complete the application for SAGES certification of your fellowship, the Fellowship Program MUST be accredited by the Fellowship Council and also be in good standing. Please exit this application now and check with your Fellowship Program or the Fellowship Council to verify program status/ Fellowship Program Director Name* Fellowship Program Director Email* Are you a SAGES Member?* Yes No If you're not a SAGES member, please join hereYear of SAGES Membership* Enter a single 4-digit year only.Are you a SAGES Active Member?* Yes No If you are not yet an Active member, please upgrade now to be eligible for certification. Contact Membership Coordinator.Year of conversion to Active SAGES membership Meetings where abstracts were submitted during Fellowship Year* SAGES ACS DDW AHPBA Obesity Week Other Other: Meetings where abstracts were presented during Fellowship Year* SAGES ACS DDW AHPBA Obesity Week Other Other: Journals where papers were published during fellowship year:* Surgical Endoscopy Surgery Journal of Surgical Research Surgery for Obesity and Related Diseases Journal of the American College of Surgery Other Other: Annual society meetings, postgraduate courses, or CME-certified hands-on courses attended during fellowship: UploadsPlease upload the final summary caselog report for this fellow from the Fellowship Council caselog system.Accepted file types: xls, csv, xlsx, Max. file size: 600 MB.This report can be downloaded by the Program Director at the following link and must be attached here. Login to your account at www.fellowshipcaselog.org Click "Manage Fellows and View Individual Logs" Click on the name of the fellow to view Look for "Summary Reports Available" and click on “Grouped by Tertiary”; please note this may take a few minutes to create Click on box labeled “Count of Procedures per Third Level Category. Grouped by Type and Role.” This will open up the report within the web page. Click on the link labeled “Export this report to CSV” Save file to your computer File must be in Excel or CSV formatPlease upload at least one abstract that was submitted to a national or regional meeting during the fellowship.*Accepted file types: pdf, doc, docx, Max. file size: 600 MB.PDF, DOC, DOCX only.Please upload a CME certificate or copy of badge from one annual society meeting, postgraduate course, or CME-certified hands-on course.*Accepted file types: pdf, doc, docx, jpg, jpeg, gif, png, Max. file size: 600 MB.PDF, DOC, DOCX, JPG/JPEG, GIF, or PNG only.Please upload your FLS certificate*Accepted file types: pdf, doc, docx, jpg, jpeg, gif, png, Max. file size: 600 MB.Please upload your FES certificateAccepted file types: pdf, doc, docx, jpg, jpeg, gif, png, Max. file size: 600 MB.PDF, DOC, DOCX, JPG/JPEG, GIF, or PNG only.Please upload your FUSE certificate. FUSE is optional but strongly encouraged for 2017-2018 fellows and will be required beginning with the 2018-19 fellowship year.Accepted file types: pdf, doc, docx, jpg, jpeg, gif, png, Max. file size: 600 MB.PDF, DOC, DOCX, JPG/JPEG, GIF, or PNG only. PaymentFellowship Certification Application FeeTotal Due on Submission $0.00 Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name Authorization for Release of InformationAuthorization* By checking this box, I authorize the Fellowship Council and the above named Fellowship Program(s) to share confidential information only as relevant to this application with SAGES. I additionally authorize SAGES to obtain confidential information only as relevant to this application from the Fellowship Council and the above named Fellowship Program(s) and hold these parties harmless for any damages resulting from this exchange of information. Information may include summaries of performance-evaluation data and other information relating to your fellowship duties.EmailThis field is for validation purposes and should be left unchanged.