Application for Associate Active Membership

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 the American College of Surgeons) that is a member of the American Board of Medical Specialties and appropriate to applicant’s specialty practice, or certification in gastroenterology by the American Board of Internal Medicine, or appropriate equivalent specialty certification by the Royal College of Physicians and Surgeons of Canada.
Applicant Information
Suffix
Institution Information
Mailing Address
Is this address located at the Institution above?
Additional Information
Gender
Indicate your surgical practice as it is now defined:
Education
College / University
Medical / Nursing School
Postgraduate Training
Internship
Residency
Fellowship
Other
Licensure / Certification

A copy of your medical license must be submitted to the SAGES office in order to complete your application.

Has your medical license ever been suspended or revoked in any state?
Have your privileges ever been suspended or changed?
Board Certification

If applicable, a copy of your board certificate(s) must be submitted to the SAGES office in order to complete your application.

Society Memberships
Select all that apply
Endoscopic / Laparoscopic Training
Was flexible endoscopy included in your surgical residency or training?
Was laparoscopic surgery included in your surgical residency or fellowship training?
Current Endoscopic / Laparoscopic Experience
Flexible GI Endoscopy (Approximate Number)
EGD
ERCP
PEG
Colonoscopy
Laparoscopic General Surgery (Approximate Number)
Laparoscopy (Diagnostic or Emergency)
Laparoscopic Cholcystectomy
Laparoscopic Choledochoscopy
Upper GI Laparoscopic Surgery
Lower GI Laparoscopic Surgery
Laparoscopic Solid Organ Removal
Academic Appointments

Please begin with the most recent.

Academic Appointment 1
Academic Appointment 2
Academic Appointment 3
Academic Appointment 4
Academic Appointment 5
Hospital Appointments

Please begin with the most recent.

Hospital Appointment 1
Hospital Appointment 2
Hospital Appointment 3
Hospital Appointment 4
Hospital Appointment 5
Letters of Recommendation

Please note: letters below must be from different people. You may not have the same person fulfill multiple roles.

Letters of recommendation have been requested from:

Attachments
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.

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Submission