Application for Membership Name * First Name Last Name Email 1 * Email 2 Practice name * Primary practice address * Home address * EDUCATION Undergraduate school attended * Degree * Year graduated * Graduate school attended (if applicable) Degree (if applicable) Year graduated Medical school attended * Degree * Year graduated * Residency program attended * Field of training (Orthopedic, Plastic, or General Surgery) * Year graduated * Hand surgery fellowship * Program director * Year graduated * BOARD CERTIFICATION American board of: * Make selection * Board Eligible Board Certified Subspecialty certificate in surgery of the hand? * Yes No CURRENT HOSPITAL AND SURGERY CENTER AFFILIATIONS Name of primary hospital? * How many hospital and surgery centers are you affiliated with? * If additional affiliations or information is needed, please enter it here. RECOMMENDATION Name of an active member, per CSSH by-laws, who will support your application * How long have you known this active member? * In what capacity is he/she familiar with you as a hand surgeon? * ADDITIONAL INFORMATION Have you ever been convicted of a felony? * Yes No Have you ever had your medical license restricted or revoked either through voluntary or involuntary action or surrender? * Yes No Have you ever had hospital membership restricted, revoked and/or denied? * Yes No Have you ever had any membership in any society and/or association restricted, revoked and/or denied? * Yes No Have you ever been censured by a state, medical society, and/or hospital? * Yes No Authorization and Release I authorize the CSSH to evaluate my application and verify all credentials and information I provide. I further authorize any individual, hospital, medical staff, or organization possessing information relevant to my qualifications to release it to the CSSH. I waive any claims or liability against those who provide such information in good faith, as well as against the CSSH, its officers, members, employees, and agents, for any actions taken in connection with this application. I acknowledge that the decision regarding my eligibility for membership rests solely with the CSSH and is final. By typing my name and submitting this application, I certify that my answers are complete, true, and correct to the best of my knowledge. Digital Signature * Thank you for submitting or application for membership!
