First Name*

Last Name*

Email*

Phone*

Ethnicity / Background*

Black

Native American

Hispanic

Caucasian

Asian

Multiracial

Prefer not to answer

Gender*

Male

Female

Prefer not to answer

Home Address*

Work Address*

Preferred Mailing Address*

Home

Work

Professional Degrees*

MD

DO

MPH

MA

MS

MBA

PhD

Other

Other (Professional Degrees)

Practice Type*

Private

Academic

Hospital Employed

Research

Industry / Government Employee

Other

Academic (Practice Type)

Other (Practice Type)

Do you hold any leadership positions?*

Yes

No

Leadership Positions

Dean

Vice-Dean

Associate Dean

Department Chief

Division Chief

Program Director

Hospital CEO

Hospital Vice-President

Other

Other (Leadership Positions)

Medical School and Year of Completion

Residency and Year of Completion*

Fellowship and Year of Completion

Membership Type*

Active (Attending, practicing, retired, etc) -$200

Candidate (Resident, Fellow, trainee) - $50

Student - Free

Interest(s): select all that apply

Membership and Nominating Committee

Fundraising Committee

Bylaws Committee

Communications Committee

Mentorship and Education Committee

Program Committee

Advocacy Committee

I would serve as a potential speaker*

Yes

No

Preferred Speaking Topics

Payment
All applications will be reviewed by the membership and executive committee. An invoice for your selected membership fee will be sent to the contact information listed on this application. You will receive a receipt when your payment has been processed.

Payment Consent*

I Agree

Background/Security
A background/security check will be required to participate certain programs spearheaded by the society. By selecting the box below, you agree to a standard background check to be conducted by a 3rd party organization.

Background/Security Consent*

I agree to a background check as needed for participation in programs within the society.

Disclaimer and Signature

Disclaimer and Signature Consent*

I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application or interview may result in disqualification of this application. If my application is accepted, I pledge to abide by the bylaws, rules and regulations, and all policies and procedures set forth by this society. I hereby agree that if my application is not acted upon favorably, I will not hold the society or any of its officers or members legally responsible for this action.

Please type your full name here. This will serve as your signature.*

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