SAGES Telementoring Study – Sleeve Gastrectomy Application FAME Telementoring Study Application Form Name* First Last Please enter your given and family name.Date of Birth* Year of Graduation from Medical School*Please enter a value between 1900 and 2015.FLS Accredited*YesNoHospital Director's Name* Institution*Is this a COE Institution / Hospital*YesNoInstitution Street Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 Country Phone- CellFaxEmail* Which of the following specialties best describes your clinical practice?*Please check all that apply Bariatric Surgery only Bariatric and General Surgery Is your center a Bariatric Center of Excelence?*YesNoHow many years have you been in practice?*0-5 years6-10 years11-15 years>15 yearsHow long have you been performing Bariatric surgery?*0-2 years3-5 years6-10 years10 or more yearsAverage number of Bariatric cases per year?How long have you been performing Sleeve Gastrectomy?1-2 years3-4 years4-6 years6 or more yearsHow many laparoscopic sleeve cases have you performed?Do you currently have privilege in your hospital to perform lap sleeve gastrectomy?YesNoIf selected to participate, will you be able to have your hospital sign off on a liability indemnification for the proctor?YesNoLocation of your PracticeHospital(s) where you have privilege to perform Bariatric surgeryYour training in General SurgeryFellowship TrainingEmailThis field is for validation purposes and should be left unchanged.