Advanced GI MIS and Flexible Endoscopy Fellowship Certificates Applications for 2023-2024 Fellows will Open in Spring 2024 SAGES Certification of Fellowship - Application "*" indicates required fields I. Advanced GI MIS and/or Comprehensive Flexible Endoscopy Certification Program Applicants will have one year – from the end of their fellowship or from Board Certification, whichever comes first – to complete the application. Fellows need to have completed training in an Advanced GI MIS and/or Comprehensive Flexible Endoscopy fellowship (can be dual or multiple designated programs) in order to apply for the certificate program. [note: Bariatrics, Foregut and Hernia & Abdominal Wall ONLY Fellowships are not eligible for this certification unless they are ALSO designated as an Advanced GI MIS and/or Comprehensive Flexible Endoscopy Application Fee: $100 CERTIFICATE REQUIREMENT BY JULY 31, 2026: - SAGES Membership: Fellows are encouraged to become part of the SAGES community of advanced MIS and endoscopic surgeons, and Active Membership in SAGES is required for the certificate program. If not already a member, we invite you to join SAGES now as a Candidate Member. Upon completion of fellowship, you can upgrade to Active Membership with a discounted fee of $165. This discount applies to an upgrade only and is not available to first time applicants to Active SAGES Membership. Members also receive discounted registration for the SAGES annual meeting. - Defined Category Cases (mandatory) - Program Director’s On-line Survey: an invitation will be sent to the Program Director once the application is received. - Submit an Abstract to a major meeting during fellowship. - FLS, FES and FUSE certification (all three are mandatory). - Attend a major meeting in person or virtually: Proof of SAGES meeting registration can count towards this requirement. II. Area of Concentrated Training (ACT) Seal-Advanced Flexible Endoscopy Certification Program Applicants will have one year – from the end of their fellowship or from Board Certification, whichever comes first – to complete the application. Application Fee: $25 CERTIFICATE REQUIREMENT BY JULY 31, 2024: - Society Certification: Proof of Society Certification affiliated with the Program's Fellowship Designation. - EPAs (See List Below) -- Must cover educational content of EPAs 1 and 2 -- Must cover educational content of 3 of the remaining EPAs - Defined category cases (Mandatory): - Program Director's On-line Surgey: an invitation will be sent to the Program Director once the application receives. - FES, and FUSE Certification (Both certifications are mandatory)This field is hidden when viewing the formSAGES Fellowship Certification Program ApplicationI hereby request a 2024-2025 Fellowship Certification in one of the following programs* 1. Advanced GI MIS and agree to pay $100 application fee. 2. Advanced GI MIS & Comprehensive Flexible Endoscopy (Combined Single Certificate) and agree to pay $100 application fee. 3. Advanced GI MIS + ACT Seal Advanced Flexible Endoscopy and agree to pay $125 application fee. 4. Comprehensive Flexible Endoscopy and agree to pay $100 application fee. Application Form01. Name:* First Name Last Name 02. Degree(s):*03. Email:* 04. Cell Phone:*05. 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Residency Program Name:*06a. Residency Program Year of Completion:*20272026202520242023202220212020before 202007. Fellowship Program Name:*07a. Fellowship Program Year of Completion:*2027202620252024202308. Please select the type of fellowship accreditation your program has from the Fellowship Council. **Please note: Bariatrics, Foregut, and/or Hernia & Abdominal Wall ONLY fellowship programs are not eligible for this certificate.* Advanced GI MIS Advanced GI MIS/Bariatrics Advanced GI MIS/Bariatrics/Comprenhensive Flexible Endoscopy Advanced GI MIS/Bariatrics/Foregut Advanced GI MIS/Comprehensive Flexible Endoscopy Comprehensive Flexible Endoscopy Comprehensive Flexible Endoscopy/Foregut 09. Is this program accredited by The Fellowship Council? Please contact your Program Director/Coordinator to obtain this information if needed.*In order to complete the application for the Advanced GI MIS certificate, your Fellowship Program MUST be accredited by the Fellowship Council and also be in good standing. You can check your program status at this link: Fellowship Program Accreditation Status Yes No 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. 10. Fellowship Program Director Name (SAGES will invite your Program Director to complete an online survey)* First Name Last Name 11. Fellowship Program Director Email* 12. Are you a SAGES Member?* Yes No Fellows are encouraged to become part of the SAGES community of advanced MIS and endoscopic surgeons, an Active Member in SAGES is required for the certificate program. If you're not a SAGES member, we invite you to join SAGES as a Candidate Member. Upon completion of fellowship, you can upgrade to an Active Membership with a discounted fee of $165. This discount applies to an upgrade only and is not available to first-time applicants to Active SAGES Membership. Members also receive discounted registration for the SAGES Annual Meeting.13. Year of SAGES Membership:20262025202420232022before 202214. Are you a SAGES Active Member? Yes No If you are not yet an Active member, please upgrade now to be eligible for certification. For additional information, please email SAGES Membership Coordinator. 15. Year of conversion to Active SAGES membershipPaymentTotal Due on Submission Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 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. EmailThis field is for validation purposes and should be left unchanged.