Application for Candidate Membership

Applicant Information
Suffix
Institution Information
Mailing Address
Is this address located at the Institution above?
Additional Information
Gender
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.

Have you applied for board certification?
Specialty Board 1
Specialty Board 2
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
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.

Meet A Member?

Would you like to meet a SAGES member?

Submission