Advanced GI MIS and Flexible Endoscopy Fellowship Certificates SAGES Certification of Fellowship Application 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: Bariatric and Foregut Fellowship 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, 2024: - 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 $150. 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-linie Surgey: an invitation will be sent to the Program Director once the application receives. - FES, and FUSE Certification (Both certifications are mandatory)HiddenSAGES Fellowship Certification Program ApplicationI hereby request a 2022-2023 Fellowship Certification in one of the following program* 1. Advanced GI MIS and agree to pay $100 application fee. 2. Comprehensive Flexible Endoscopy and agree to pay $100 application fee. 3. Advanced GI MIS and Comprehensive Flexible Endoscopy (Combined Single Certificate) and agree to pay the fee of $100 application fee. 4. Advanced GI MIS and ACT Seal and agree to pay the fee of $125 application fee. Application Form01. Name: First Name Last Name 02. Degree(s): 03. Email: 04. Cell Phone:05. 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Residency Program and Year of Completion:2025202420232022202120202019201807. Fellowship Program and Year of Completion:2025202420232022202120202019201808. Type of Fellowship, please select one the following program types. [note: Bariatric and Foregut fellowship are not eligible for this application]* Advanced GI MIS Advanced GI MIS/Bariatric Advanced GI MIS/Bariatric/Flexible Endoscopy Advanced GI MIS/Flexible Endoscopy Flexible Endoscopy 09. Is this program accredited by The Fellowship Council?* 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 If you're not a SAGES member, please join here13. Year of SAGES Membership:20252024202320222021202020192018201720162015201414. 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 membership 16. How would you like to be more involved in SAGES? Serve on a SAGES Committee Leadership and Career Development Opportunities Research Grant and Award Opportunities Be Considered for a presentation in a national meeting PaymentTotal 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. EmailThis field is for validation purposes and should be left unchanged.