Join the ISS

Membership Application Procedure

Applications are made at the invitation of any member who will act as the Sponsor of the Applicant.
If an applicant does not know a current member that can sponsor their application the Illinois Surgical Society Board of Governors will find sponsors for them.
The candidate shall complete all portions of the online application form (below).
The year and number of his/her Specialty Board certification(s) should be given.
All bibliographic listings should be given in standard form, in chronological order, and should include ALL authors' names in the order in which the names appear in the original publications.

* Indicates required field

To the Membership Committee of the Illinois Surgical Society:
I hereby make application for membership in the Illinois Surgical Society.

Applicant Name
First Name:
Middle Name:
Last Name:
Contact Information - Office
Address (Line 1):
Address (Line 2):
City:
State:
Zip Code:
Telephone:
Fax:
Contact Information - Residence
Address (Line 1):
Address (Line 2):
City:
State:
Zip Code:
Telephone:
Applicant Information
Email:
Credentials:
Spouse:
Specialty:
Age:
Date of Birth (MM/DD/YYYY format):
Place of Birth:
Are you a citizen of the United States of America?	Yes No
If a naturalized citizen, state where and when you were naturalized:
Military Record:
Branch of Service:
Rank:
Dates of Service:

Sponsors / Endorsers
Sponsor:	Name: Email:
Endorser #1:	Name: Email:
Endorser #2:	Name: Email:

To the Membership Committee of the Illinois Surgical Society:
For your information, I submit the following data concerning my medical education and surgical experience.

Premedical Education
University or College:		Degree:
Years:
University or College:		Degree:
Years:
Medical Education
Medical School:		Degree:
Years:
Medical School:		Degree:
Years:
Internship
Hospital:		Years:
Hospital:		Years:
Surgical Residency and/or Fellowship (hospital dates and position in hospital):

Surgical Experience, Investigative Work and Other Postgraduate Work in Addition to Surgical Fellowship or Residency; As Assistant or Associate With a Surgeon; In Medical School and Dispensaries; In Experimental Laboratories; In Clinics; In Postgraduate Courses, Etc. (under whose guidance)

Past Hospital Associations and Appointments (and dates):

Past Medical School Associations and Appointments (and dates):

Present Hospital Associations and Appointments (and dates):

Present Medical School Associations and Appointments (and dates):

Practice Limited To:

Certificate(s) of American Board of Surgery or Board of Allied Specialties
Board Name:		Date:
Certificate Number:
Board Name:		Date:
Certificate Number:
Board Name:		Date:
Certificate Number:
Membership in Other Medical and Surgical Societies:

List of Chief Contributions to Medical and Surgical Literature with Date and Place of Publications:

* I agree, if elected to the society, to attend its meetings and to contribute to the meetings by the presentation of papers and by entering into the discussions.
* What is 6 + 2? (This is to ensure the form is being submitted by a person, not an automated spamming script.)