ࡱ> KMHIJP )qbjbj jjDHgl$@666P7TT8@ ;:FJFJFJFJY fn$ ƍpqU.YqqtFJFJ Rtttq8FJFJtqttwz[{FJ; BKt@p46{r,/{[{< h0E{6t6[{t@@ American College of Surgeons FOUNDED BY SURGEONS OF THE UNITED STATES AND CANADA, 1913 633 North St. Clair Street Chicago, Illinois 60611  Application for Fellowship Checklist  PLEASE READ BEFORE COMPLETING APPLICATION  Eligibility Requirements  FORMCHECKBOX  I am certified in my specialty by a member Board of the American Board of Medical Specialties or by the Royal College of Physicians and Surgeons of Canada.  FORMCHECKBOX  I have practiced surgery for at least one year after the completion of all formal training.  FORMCHECKBOX  I hold a full and unrestricted license to practice medicine and surgery in the state or province where I practice and know of no adverse actions that would affect the status of my licensure.  FORMCHECKBOX  I hold a current appointment on the surgical staff of a hospital with no reportable action pending that could adversely affect staff privileges at any hospital.  FORMCHECKBOX  I practice as a general surgeon or as a surgical specialist within the scope of my specialty. Surgical Case List You must be able to provide the College with a surgical case list reflecting the type and volume of surgical cases you have performed during the past year. Please do not submit this list until requested to do so. Application Fee Applicants who are not Associate Fellows are required to pay an application fee of $150.00 (US). This fee must be submitted with the application and is not refundable. Applications will not be processed until the application fee has been received. Additional Information Please read the Fellowship Requirements and American College of Surgeons Bylaws before completing your application. Additional information may be obtained from the American College of Surgeons website at www.facs.org or by calling the Credentials Section of the Division of Member Services at 800-293-9623.  INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR FELLOWSHIP This form is designed to provide applicants with the opportunity to record their recognized periods of training and experience for each year since graduating from medical school. Each item on the application must be completed in full. Attachment or submission of a curriculum vitae does not suffice. The deadline for receipt of applications is September 15th of any given year. All applicants are required to sign the Fellowship Pledge and the Authorization to Release Information. Your signature will be requested upon receipt of your completed application. Do not use the enter key to move throughout this document. You must hit tab to move from field to field. Check boxes are activated by using the space bar. Your attention is directed to the margin notes on the application form and to the following numbered items. A full and unrestricted license from the state/province, or states/provinces, in which the applicant is practicing at the time the application is being considered is a primary requirement. The type of practice should be clearly defined (solo, partnership, group, full- or part-time medical school, clinic, or other). A combination of two or more types of practices may be entered. Postdoctoral education (internships, residencies, or fellowships) in hospitals or clinics, listing only those involving full-time service. Primary hospital refers to the hospital where you do the major portion of your surgery. The official title of the staff position (for example, active, attending, courtesy, provisional, and so on) that is assigned by the governing body of the hospital should be given. Academic appointments should not be recorded as a hospital staff position. (Do not include hospital appointments during postdoctoral training.) All medical societies, academies, or colleges (local, state or provincial, regional, and national) in which you have current membership or fellowship. Attach a separate listing or curriculum vitae. REMINDER Before you return the completed application form, please be sure that you have: Included the $150.00 (U.S.) application fee. (Associate Fellows are exempt.) Payment options are listed at the end of the application. Reviewed pledge and authorization. (To be signed at a later date.) Enclosed any necessary attachments (item 12). Retained a duplicate copy for later reference. THE FOLLOWING APPLICATION IS FOR ELECTRONIC SUBMISSION ONLY. A PRINTABLE VERSION IS AVAILABLE AT http://www.facs.org/memberservices/documents.html#application YOU MAY E-MAIL YOUR COMPLETED APPLICATION TO: facsapplications@facs.org  American College of Surgeons FOUNDED BY SURGEONS OF THE UNITED STATES AND CANADA, 1913 633 North St. Clair Street Chicago, Illinois 60611  Refer to Instruction Sheet  Application for Fellowship  Name  FORMTEXT       Mailing Address  FORMTEXT       City/State/Zip  FORMTEXT       Country  FORMTEXT       Office Telephone No.  FORMTEXT       Fax No.  FORMTEXT       E-mail  FORMTEXT       Date of Birth  FORMTEXT       Gender Male FORMCHECKBOX  Female FORMCHECKBOX   1. LicensureName of State, Province, or CountryLicenseLicense NumberOriginal Issuance Date FORMTEXT      Full  FORMCHECKBOX Restricted  FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Full  FORMCHECKBOX Restricted  FORMCHECKBOX  FORMTEXT       FORMTEXT       Status of LicensureHave you ever had your license or any right associated with the practice of medicine restricted, rescinded, or placed on probation through governmental action or voluntary surrender? Yes  FORMCHECKBOX  No  FORMCHECKBOX  (If yes, please record details in Addendum 1 at the end of this application.) 3. Certification by American Specialty BoardsName of Specialty Board Date of CertificationCertificate Number FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       3a. Canadian College CertificationSurgical Specialty Date of CertificationFellowship FORMTEXT       FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  3b. Other National or Royal College Fellowship or CertificationName of Certifying BoardFellowship or CertificationDate FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       4. Surgical Practice Information4a. Type of Practice:  FORMCHECKBOX Solo  FORMCHECKBOX Partnership  FORMCHECKBOX Group  FORMCHECKBOX Clinic  FORMCHECKBOX Full-time Academic  FORMCHECKBOX  Other  FORMTEXT      4b. Composition of Surgical Practice: Colon & Rectal, General, Neurological, Ophthalmic, Orthopaedic, Pediatric, Plastic, Thoracic, or Vascular Surgery; Gynecologic Oncology, Obstetrics & Gynecology, Otolaryngology, UrologySpecialty(ies)Percentage (to equal 100%) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      4c. Site of Practice (Facilities used for operative procedures): Record % at each type of facility (to equal 100%) Hospital In-patient  FORMTEXT       Hospital Out-patient  FORMTEXT       Free-standing Facility  FORMTEXT       Office  FORMTEXT      4d. Date of Entry into Surgical Practice: Month  FORMTEXT       Year  FORMTEXT       5. Academic Appointments (after completion of all formal training)Full Name and Location of Medical SchoolOfficial Title of Faculty Position (E.g. Instructor, Assistant Professor, etc.)From (mm/yy)To (mm/yy) FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       6. Medical SchoolFull Name and Location of Medical SchoolDegreeGrad. DateFrom (mm/yy)To (mm/yy) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       7. Graduate Degree(In addition to MD) Full Name and Location of InstitutionDegreeFrom (mm/yy)To (mm/yy) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       8. Postdoctoral Training (Level  please indicate intern, resident, etc.; To and From  please list both month and year)Full Name and Location of InstitutionLevelDepartmentFrom (mm/yy)To (mm/yy) FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT      9. Hospital Appointments Primary Hospital (the hospital where you do the major portion of your surgery) Full Name and Location of HospitalSurgical Staff Position (E.g. Active, attending, etc.)From (mm/yy)To (mm/yy) FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT      List ALL OTHER PAST AND PRESENT Hospital Appointments, including ambulatory surgical facilities (exclude any appointments while in postdoctoral training) FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT       FORMDROPDOWN  FORMTEXT       FORMTEXT       9a. Has any hospital ever denied your request for any type of surgical privileges? & & & & & & & & & ..  FORMCHECKBOX  yes  FORMCHECKBOX  no Has any hospital reduced, restricted, suspended, terminated, or requested you to resign all or any portion of your surgical staff privileges, or is any attempt to do so now in progress?  FORMCHECKBOX  yes  FORMCHECKBOX  no Has any hospital imposed supervision, compulsory consultation, or probation, or is any attempt to do so now in progress?  FORMCHECKBOX  yes  FORMCHECKBOX  no Has your medical malpractice insurance ever been denied? ...  FORMCHECKBOX  yes  FORMCHECKBOX  no (If the answer to any of these questions is yes, record the details in Addendum 2 at the end of this application.) 10. Military ServiceBranch, Assignment and RankFromTo FORMTEXT       FORMTEXT       FORMTEXT       11. Current Medical Society, Academy, or College Memberships FORMTEXT       12. Published Contributions to Medical and Surgical Literature (Please provide CV as a separate attachment) FORMTEXT       References The names of FIVE Fellows of the ACS who practice in your geographic area (Note: applicants practicing as full-time military surgeons may submit their references from any location) and who should have been contacted and have agreed to serve as references on the basis of their actual knowledge of your current surgical practice. Two of these FACS should represent your surgical specialty. The FACS listed should not be relatives or partners in practice.NameAddress FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      13a. Chief Reference List the name of the Chief of Surgical Service at your primary hospital even if listed above. Name of ChiefAddress FORMTEXT       FORMTEXT       14. Other Information If after the date you finished your medical education, any period of 6 months or more is not accounted for elsewhere on this application, please record the appropriate information below.Professional Activities (research, general practice, other study, or other employment.)Location (City & State/Province)From (mm/yy)To (mm/yy) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Addendum 1  If you answered yes to question #2, please provide your response here. FORMTEXT       FORMTEXT       Addendum 2  If you answered yes to any part of question #9a, please provide your response here. FORMTEXT         PAYMENT INFORMATION  FORMCHECKBOX  I am a current Associate Fellow (No fee required)  FORMCHECKBOX  I am submitting payment via credit card Select One  FORMCHECKBOX  Visa  FORMCHECKBOX  Mastercard  FORMCHECKBOX  American Express Card Holder Name:  FORMTEXT       Credit Card Number:  FORMTEXT       Expiration Date:  FORMTEXT        FORMCHECKBOX  I am submitting a $150 check to the following address: Attention: Cynthia Hicks American College of Surgeons Credentials Section 633 North St. Clair Street Chicago, Illinois 60611-3211 If submitting a check, please submit a cover letter indicating that your application was submitted electronically. YOU MAY E-MAIL YOUR COMPLETED APPLICATION TO: facsapplications@facs.org By submitting this document, you are agreeing to the terms listed below in the Authorization to Release Information and to abide by the Fellowship Pledge. Once we have received your application, your personal signature will be required to complete your application. AUTHORIZATION TO RELEASE INFORMATION In furtherance of my application for Fellowship in the American College of Surgeons, I hereby request and authorize any hospital or medical staff where I now have, have had, or have applied for medical staff privileges, and any medical organization of which I am a member or to which I have applied for membership, and any person, who may have information (including medical records, patient records, and reports of committees, including tissue committees) which is deemed by the American College of Surgeons to be material to its evaluation of my fitness for Fellowship, to provide such information to representatives of the College upon their request. I agree that communications of any nature made to the College regarding my fitness for Fellowship may be made in confidence and shall not be made available to me under any circumstances. I hereby release from liability any hospital, medical staff, medical organization or person, and the American College of Surgeons and its representatives, from liability for acts performed in good faith in connection with the provision, collection, evaluation of information or opinions, whether or not requested or solicited, in connection with my application for Fellowship in the American College of Surgeons. I understand and agree that as an applicant for Fellowship, I have the responsibility for supplying to the College information adequate for the proper evaluation by the College of my fitness for Fellowship. I further agree that I will not cause or attempt to cause any public disclosure of the contents of any application for Fellowship, including my own, or any proceedings of any committees evaluating such applications, where such disclosure is by operation of law or otherwise.  In making application for Fellowship in the American College of Surgeons, I agree to abide by the Bylaws of the College, and by such rules and regulations as may be enacted from time to time, and I subscribe to the Fellowship pledge as follows: FELLOWSHIP PLEDGE Recognizing that the American College of Surgeons seeks to exemplify and develop the highest traditions of our ancient profession, I hereby pledge myself, as a condition of Fellowship in the College, to live in strict accordance with the College's principles and regulations. I pledge to pursue the practice of surgery with honesty and to place the welfare and the rights of my patient above all else. I promise to deal with each patient as I would wish to be dealt with if I was in the patient's position and I will respect the patient's autonomy and individuality. I further pledge to affirm and support the social contract of the surgical profession with my community and society. I will take no part in any arrangement or improper financial dealings that induce referral, treatment, or withholding of treatment for reason other than the patient's welfare. Upon my honor, I declare that I will advance my knowledge and skills, will respect my colleagues, and will seek their counsel when in doubt about my own abilities. In turn, I will willingly help my colleagues when requested. I recognize the interdependency of all healthcare professionals and will treat each with respect and consideration. Finally, by my Fellowship in the American College of Surgeons, I solemnly pledge to abide by the Code of Professional Conduct and to cooperate in advancing the art and science of surgery. To use this application properly you must right click on the Application for Fellowship link on our website and choose save target as. Save the document to your desktop, complete it, save your changes, then email it to us as an attachment to facsapplications@facs.org. 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