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Application for Membership

1 Member Type

2 Contact Information

3 Education

4 Licensure / Certification

5 Allied Health Licensure / Certification

6 Endoscopic / Laparoscopic Training

7 Academic Appointments

8 Hospital Appointments

9 Referral

10 Letters of Recommendation

11 Payment

Are you a Board Certified Surgeon?*
- Yes
- No
Please select your current country of practice/residence*
Are you currently in a surgical residency or fellowship program?*
- Yes
- No
Please select the option that most closely matches*
- I am still in Medical School
- I am an OR nurse or surgical technician
- I am an MD or PhD involved with MIS but I am not a surgeon
Your Membership Category*

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Which member type are you applying for?*
Member 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 Surgeons
Associate 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
1. Graduation from a medical school acceptable to SAGES.
2. 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 Information
Name*
Prefix 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 Number
Cell Phone
Institution/Company Name
Department
Title
Example: Director of Surgery
Institutional / Company Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Is the institution's address your preferred mailing address?*
- Yes
- No
Secondary Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional Information
Date of Birth*
Country of Birth
Gender*
- Male
- Female
- I 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 Solo
- Private Practice Group
- Private Practice / Part-time HMO
- Full-time HMO or IPA
- Full-time Academic
- Full-time Government (VA)
- Military
I consider myself to be primarily:*
- Community Practice Surgeon
- Academic Surgeon

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Education

College / University*

Institution	Degree	Year Awarded

Medical / Nursing School*

Institution	Degree	Year Awarded

Postgraduate Training

Institution	Degree	Year Awarded

Internship

Institution	Program Director	Start Year	End Year

Residency

Institution	Program Director	Start Year	End Year

Fellowship

Institution	Program Director	Start Year	End Year

Other Applicable Training

Type of Training	Institution	Program Director	Start Year	End 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.*

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Licensure / Certification
A 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 license
In which country are you licensed to practice medicine?*
In which state are you licensed to practice medicine?*
Registry Number*
Medical License Expiration Date*
Has your medical license ever been suspended or revoked in any state or country?*
- Yes
- No
Please provide a brief explanation as to why your license was revoked or suspended.*
Have your privileges ever been suspended or changed?*
- Yes
- No
Please 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 Certification
If 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 Memberships
If 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

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Allied Health Licensure / Certification
Medical 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?*
- Yes
- No
Have your privileges ever been suspended or changed?*
- Yes
- No
Board Certification

I am board certified by

Issuing Board	Certificate Number	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.

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Was flexible endoscopy included in your surgical residency or training?
- Yes
- No

Who were your flexible endoscopy instructors?

To add multiple instructors, please click on the plus sign to the right of the field.

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Remove this row

Was laparoscopic surgery included in your surgical residency or training?
- Yes
- No

Who were your laparoscopic surgery instructors?

To add multiple instructors, please click on the plus sign to the right of the field.

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Remove this row

Did you receive the training from a course or program? Please indicate and specify location and date.

Course/Program Instructor

To add multiple instructors, please click on the plus sign to the right of the field.

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Remove this row

Training outside formal program
Flexible GI Endoscopy (Approximate Number)
EGD
EGD # in past 12 months
EGD # in past 3 years
EGD # Complications
Have you taught EGD?
- Yes
- No
ERCP
ERCP # in past 12 months
ERCP # in past 3 years
ERCP # Complications
Have you taught ERCP?
- Yes
- No
PEG
PEG # in past 12 months
PEG # in past 3 years
PEG # Complications
Have you taught PEG?
- Yes
- No
Colonoscopy
Colonoscopy # in past 12 months
Colonoscopy # in past 3 years
Colonoscopy # Complications
Have you taught Colonoscopy?
- Yes
- No
Laparoscopic General Surgery (Approximate Number)
Laparoscopy (Diagnostic of Emergency)
Laparoscopy # in past 12 months
Laparoscopy # in past 3 years
Laparoscopy # Complications
Have you taught Laparoscopy?
- Yes
- No
Laparoscopic Cholcystectomy
Laparoscopic Cholcystectomy # in past 12 months
Laparoscopic Cholcystectomy # in past 3 years
Laparoscopic Cholcystectomy # Complications
Have you taught Laparoscopic Cholcystectomy?
- Yes
- No
Laparoscopic Choledochoscopy
Laparoscopic Choledochoscopy # in past 12 months
Laparoscopic Choledochoscopy # in past 3 years
Laparoscopic Choledochoscopy # Complications
Have you taught Laparoscopic Choledochoscopy?
- Yes
- No
Upper GI Laparoscopic Surgery
Upper GI Laparoscopic Surgery # in past 12 months
Upper GI Laparoscopic Surgery # in past 3 years
Upper GI Laparoscopic Surgery # Complications
Have you taught Upper GI Laparoscopic Surgery?
- Yes
- No
Lower GI Laparoscopic Surgery
Lower GI Laparoscopic Surgery # in past 12 months
Lower GI Laparoscopic Surgery # in past 3 years
Lower GI Laparoscopic Surgery # Complications
Have you taught Lower GI Laparoscopic Surgery?
- Yes
- No
Laparoscopic Solid Organ Removal
Laparoscopic Solid Organ Removal # in past 12 months
Laparoscopic Solid Organ Removal # in past 3 years
Laparoscopic Solid Organ Removal # Complications
Have you taught Laparoscopic Solid Organ Removal?
- Yes
- No

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How many Hospital Appointments do you have to enter?
Hospital Appointment 1
Institution
Start Year
End Year
Hospital Appointment 2
Institution
Start Year
End Year
Hospital Appointment 3
Institution
Start Year
End Year
Hospital Appointment 4
Institution
Start Year
End Year
Hospital Appointment 5
Institution
Start Year
End Year

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Referral (Optional)
Describe your current job position.
Why do you want to join SAGES?
Who referred you to SAGES?

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Letters of Recommendation
Please 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 Email
Please 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 Email
Please 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 Email
Please 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

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Total
$0.00
Credit Card*
American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name

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Newsletter Subscriptions

Name*
First Last
Email*
Comments
This field is for validation purposes and should be left unchanged.

Important Links

SAGES 2018 Meeting Information

Our Advance Program is now available for download. Advance Program too big/too long? Download the Schedule at a Glance instead!

Online Registration is now available. . Please be sure to register before February 23, 2018 to obtain the early registration discount.

Healthy Sooner: Patient Information

Contact SAGES

Society of American Gastrointestinal and Endoscopic Surgeons
11300 W. Olympic Blvd Suite 600
Los Angeles, CA 90064 USA
webmaster@sages.org
Tel: (310) 437-0544

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