Application for Membership 1 Member Type2 Contact Information3 Education4 Licensure / Certification5 Allied Health Licensure / Certification6 Endoscopic / Laparoscopic Training7 Academic Appointments8 Hospital Appointments9 Referral10 Letters of Recommendation11 Payment Are you a Board Certified Surgeon?*YesNoPlease select your current country of practice/residence*SelectAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia And HerzegowinaBotswanaBrazilBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCote D'IvoireCroatia (Local Name: Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic Of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic OfKorea, Republic OfKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldova, Republic OfMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts And NevisSaint LuciaSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia, South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre And MiquelonSudanSurinameSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic OfThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaVietNamVirgin Islands (British)Virgin Islands (US)Wallis And Futuna IslandsYemenYugoslaviaZambiaZimbabweAre you currently in a surgical residency or fellowship program?*YesNoPlease select the option that most closely matches*I am still in Medical SchoolI am an OR nurse or surgical technicianI am an MD or PhD involved with MIS but I am not a surgeonYour Membership Category* Which member type are you applying for?*ActiveAssociate ActiveAllied Health ProfessionalInternational 1International 2International 3CandidateMedical StudentMember Application Fee Price: $100.00 Candidate Member Application Fee Price: $70.00 Medical Student Application Fee Price: $40.00 Active Membership Requirements Practice within the United States, Canada or Puerto Rico. License to practice medicine in his/her state, province or country. Applicant may be in government service not requiring licensure. Certification by the American Board of Surgery, the American Board of Osteopathic Surgery, fellowship in the Royal College of Surgeons, Canada, or fellowship in the American College of SurgeonsAssociate Active Membership Requirements Practice within the United States, Canada or Puerto Rico. License to practice medicine in his/her state, province or country. Applicant may be in government service not requiring licensure. Certification by an American Surgical Specialty Board (other than certifications recognized for eligibility for regular SAGES Active Membership) which is a member of the American Board of Medical Specialties and which is appropriate to the applicant’s specialty practice, or certification in gastroenterology by the American Board of Internal Medicine, or an appropriate equivalent specialty certification by the Royal College of Physicians and Surgeons of Canada.International Membership Requirements Endoscopic/Laparoscopic surgeons outside the US, who are licensed to practice medicine and have the equivalent of a Surgical Board Certificate for the country in which they practice. Endoscopic/Laparoscopic surgeons who were originally trained & certified to practice surgery in another country, and are now licensed and practicing in the US; but who do not meet the American Board requirements for Active Membership.Allied Health Professional Membership Requirements Eligiblity for nurses, surgical technicians, physician assistants and endoscopy technicians, researchers, other surgical disciplines using endocsopic or laparoscopic techniques, and other interested allied health personnel who are actively participating in the practice or research of endoscopic or minimal access surgery.Candidate Membership Requirements Graduation from a medical school acceptable to SAGES. Current status as either: A resident or fellow enrolled in an accredited program of surgical education or research, or A surgeon who has completed an accredited surgical education program and is awaiting Board certification.Medical Student Membership Requirements Must be currently enrolled in Medical School.Contact InformationName* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First Middle Last Suffix (II, III, IV, Jr, Sr) Degrees (MD, PhD, DO, FACS, FRCS etc.)Primary Email*SAGES strongly recommends using a non-hospital/institution (e.g. Gmail, Yahoo, or similar) email for membership purposes. Secondary Email Office Phone*Fax NumberCell Phone*Institution/Company Name*DepartmentTitleExample: Director of SurgeryInstitutional / Company Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Is the institution's address your preferred mailing address?*YesNoSecondary Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Additional InformationDate of Birth* Country of BirthGender*MaleFemaleI do not wish to disclose this information.What is your surgical specialty?* Colorectal MIS Bariatric Hepatobiliary Flexible Endoscopy General Surgery Gastrointestinal Other Indicate your surgical practice as it is now defined.*Private Practice SoloPrivate Practice GroupPrivate Practice / Part-time HMOFull-time HMO or IPAFull-time AcademicFull-time Government (VA)MilitaryI consider myself to be primarily:*Community Practice SurgeonAcademic Surgeon EducationCollege / University*InstitutionDegreeYear Awarded Medical / Nursing School*InstitutionDegreeYear Awarded Postgraduate TrainingInstitutionDegreeYear Awarded InternshipInstitutionProgram DirectorStart YearEnd Year ResidencyInstitutionProgram DirectorStart YearEnd Year FellowshipInstitutionProgram DirectorStart YearEnd Year Other Applicable TrainingType of TrainingInstitutionProgram DirectorStart YearEnd Year When do you expect to complete your surgical training?* If you are a resident, which year of residency are you in? If you are a fellow, please choose Fellow.*InternPGY-1PGY-2PGY-3PGY-4PGY-5PGY-6PGY-7PGY-8Fellow Licensure / CertificationA copy of your medical license must be submitted to the SAGES office in order to complete your application. Do you have a medical license?*Yes, I have a medical license.No, I do not have a medical licenseIn which country are you licensed to practice medicine?*United StatesCanadaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweIn which state are you licensed to practice medicine?*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificRegistry Number*Medical License Expiration Date* Has your medical license ever been suspended or revoked in any state or country?*YesNoPlease provide a brief explanation as to why your license was revoked or suspended.*Have your privileges ever been suspended or changed?*YesNoPlease provide a brief description of how your privileges changed.*Please upload a copy of your medical license.*If you do not have a copy on hand, please use the "Save and Continue" option at the bottom of this page. A link will be sent to your email, allowing you to resume your application. PLEASE NOTE: All documents must be submitted in English or with an English translation.Accepted file types: jpg, gif, png, pdf, doc.Board CertificationIf applicable, a copy of your board certificate(s) must be submitted to the SAGES office in order to complete your application. I am certified by the American Board of Surgery I am certified by the American Board of Osteopathic Surgery I am certified by the American College of Surgeons I am certified by the Royal College of Surgeons I am certified by the Royal College of Physicians and Surgeons of Canada I have certification or official documentation to practice surgery. I am certified by the American Board of Internal Medicine I am certified by the American Surgical Specialty Board ABS Certificate Number*ABS Certificate Expiration Date* ABOS Certificate Number*ABOS Certificate Expiration Date* ACS Certificate Number*ACS Certificate Expiration Date* RCS Certificate Number*RCS Certificate Expiration Date* ABIM Certificate Number*ABIM Certificate Expiration Date* ASSB Certificate Number*ABIM Certificate Expiration Date* Please upload a copy of each certification you designated above.*PLEASE NOTE: All documents must be submitted in English or with an English translation. Drop files here or Accepted file types: jpg, gif, png, pdf. Society MembershipsIf you are a member of any societies listed below, which ones? Fellow of the ACS IPEG AWS AMA ASCRS ASGE SSAT EAES AOA ASMBS ELSA JSES GSA CAGS FELAC/ALACE SBAS SAAS Allied Health Licensure / CertificationMedical License A license is not issued by my profession. Issuing Body*Registry Number*License Expiration Date* Has your medical license ever been suspended or revoked in any state or country?*YesNoHave your privileges ever been suspended or changed?*YesNoBoard CertificationI am board certified byIssuing BoardCertificate NumberExpiration Date Please upload a copy of each certification you designated above.PLEASE NOTE: All documents must be submitted in English or with an English translation. Drop files here or Accepted file types: jpg, gif, png, pdf. Was flexible endoscopy included in your surgical residency or training?YesNoWho were your flexible endoscopy instructors?To add multiple instructors, please click on the plus sign to the right of the field. Was laparoscopic surgery included in your surgical residency or training?YesNoWho were your laparoscopic surgery instructors?To add multiple instructors, please click on the plus sign to the right of the field. Did you receive the training from a course or program? Please indicate and specify location and date.Course/Program InstructorTo add multiple instructors, please click on the plus sign to the right of the field. Training outside formal programFlexible GI Endoscopy (Approximate Number)EGDEGD # in past 12 monthsEGD # in past 3 yearsEGD # ComplicationsHave you taught EGD? Yes No ERCPERCP # in past 12 monthsERCP # in past 3 yearsERCP # ComplicationsHave you taught ERCP? Yes No PEGPEG # in past 12 monthsPEG # in past 3 yearsPEG # ComplicationsHave you taught PEG? Yes No ColonoscopyColonoscopy # in past 12 monthsColonoscopy # in past 3 yearsColonoscopy # ComplicationsHave you taught Colonoscopy? Yes No Laparoscopic General Surgery (Approximate Number)Laparoscopy (Diagnostic of Emergency)Laparoscopy # in past 12 monthsLaparoscopy # in past 3 yearsLaparoscopy # ComplicationsHave you taught Laparoscopy? Yes No Laparoscopic CholcystectomyLaparoscopic Cholcystectomy # in past 12 monthsLaparoscopic Cholcystectomy # in past 3 yearsLaparoscopic Cholcystectomy # ComplicationsHave you taught Laparoscopic Cholcystectomy? Yes No Laparoscopic CholedochoscopyLaparoscopic Choledochoscopy # in past 12 monthsLaparoscopic Choledochoscopy # in past 3 yearsLaparoscopic Choledochoscopy # ComplicationsHave you taught Laparoscopic Choledochoscopy? Yes No Upper GI Laparoscopic SurgeryUpper GI Laparoscopic Surgery # in past 12 monthsUpper GI Laparoscopic Surgery # in past 3 yearsUpper GI Laparoscopic Surgery # ComplicationsHave you taught Upper GI Laparoscopic Surgery? Yes No Lower GI Laparoscopic SurgeryLower GI Laparoscopic Surgery # in past 12 monthsLower GI Laparoscopic Surgery # in past 3 yearsLower GI Laparoscopic Surgery # ComplicationsHave you taught Lower GI Laparoscopic Surgery? Yes No Laparoscopic Solid Organ RemovalLaparoscopic Solid Organ Removal # in past 12 monthsLaparoscopic Solid Organ Removal # in past 3 yearsLaparoscopic Solid Organ Removal # ComplicationsHave you taught Laparoscopic Solid Organ Removal? Yes No How many Academic Appointments do you have to enter?012345 (maximum)Academic Appointment 1InstitutionTitlePositionClinicalFull TimeStart YearEnd YearAcademic Appointment 2InstitutionTitlePositionClinicalFull TimeStart YearEnd YearAcademic Appointment 3InstitutionTitlePositionClinicalFull TimeStart YearEnd YearAcademic Appointment 4InstitutionTitlePositionClinicalFull TimeStart YearEnd YearAcademic Appointment 5InstitutionTitlePositionClinicalFull TimeStart YearEnd Year How many Hospital Appointments do you have to enter?012345 (maximum)Hospital Appointment 1InstitutionStart YearEnd YearHospital Appointment 2InstitutionStart YearEnd YearHospital Appointment 3InstitutionStart YearEnd YearHospital Appointment 4InstitutionStart YearEnd YearHospital Appointment 5InstitutionStart YearEnd Year Referral (Optional)Describe your current job position.Why do you want to join SAGES?Who referred you to SAGES? Letters of RecommendationPlease note: Letters below must be from different people. You may not have the same person fulfill multiple roles. All documents must be submitted in English or with an English translation.Proxy I am unable to find a sponsor and am requesting a proxy be assigned to me. SAGES Sponsor First Last SAGES Sponsor EmailPlease provide your sponsor's email address, and they will be sent a request to upload your Letter of Recommendation. Surgical Colleague First Last Surgical Colleague EmailPlease provide your colleague's email address, and they will be sent a request to upload your Letter of Recommendation. Program Director or Chair First Last Program Director or Chair EmailPlease provide your Program Director or Chair's email address, and they will be sent a request to upload your Letter of Recommendation. Upload Letters of Recommendation Drop files here or Accepted file types: jpg, gif, png, pdf, doc, docx. Signature*By typing my full name in the space below, I authorize the Society of American Gastrointestinal and Endoscopic Surgeons to obtain information from societies, hospital staffs, members, and any other source regarding this application and my qualifications for membership, which information will be kept confidential by the Society.Promo Code Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name