2023-2024 SAGES Advanced Flexible Endoscopy Area of Concentrated Training (ACT) Seal – Application "*" indicates required fields I. Area of Concentrated (ACT) Seal in 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, 2025: – 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-linie Surgey: an invitation will be sent to the Program Director once the application receives. – FES, and FUSE Certification (Both certifications are mandatory)Application FormI hereby request a 2023-2024 Fellowship Certification in the following program:* 2023-2024 SAGES Advanced Flexible Endoscopy Area of Concentrated Training (ACT) Seal 01. Name: First Name Last Name 02. Degree(s):* 03. Email:* 04. Cell Phone:*05. 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Residency Program:*2025202420232022202120202019201806a. Year of Completion Residency Program:*2025202420232022202120202019201807. Fellowship Program:*2025202420232022202120202019201807a. Year of Completion Fellowship Program:*202520242023202220212020Before 202008. Type of Fellowship, please select one of the following program types.* Bariatrics Complex GI Surgery Foregut HPB 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 Area of Concentrated (ACT) Seal in Flexible Endoscopy, 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 and EPA attestation)* First Name Last Name 11. Fellowship Program Director Email* 12. Which sponsoring society will you be applying to for certification?* 13. Are you a SAGES Member? Yes No If you’re not a SAGES member, please visit herePaymentFellowship Certification Application FeeTotal Due on Submission Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 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.