Deadline for Receipt of Materials Is October 1st Survey

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OTHER INFO:

Home street address

Home city

Home state

Home zip

Home country

Spouse name

Send Society correspondence & publications to home or office?

Hobbies/Interests

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PROPOSERS:

Proposed by

Seconded by

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PAPERS/PUBLICATIONS:

Number of papers you have presented at Triological Society meetings within the last five years

Number of papers you have presented at other national or international meetings within the past five years

Number of scientific publications in peer reviewed journals as first or senior author

Total number of scientific publications in peer reviewed journals (may include publications during residency)

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MEETINGS: Number of national or international meetings other than Triological Society for which you registered and attended in the past five years

2019 - 2023

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TRAINING Please be sure to provide complete information

College 1 [ 1. name 2. what years attended 3. degree ]

College 2 [ 1. name 2. what years attended 3. degree ]

PostGrad 1 [ advanced degree (excluding medical school) ]

PostGrad 2 [ advanced degree (excluding medical school) ]

Medical School [ 1. name 2. what years attended 3. degree ]

Internship 1 [ 1. where 2. what years 3. type ]

Internship 2 [ 1. where 2. what years 3. type ]

Residency 1 [ 1. where 2. what years 3. type ]

Residency 2 [ 1. where 2. what years 3. type ]

Fellowship 1 [ 1. where 2. what years 3. type ]

Fellowship 2 [ 1. where 2. what years 3. type ]

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ALL CURRENT APPOINTMENTS: Hospital and teaching (i.e. type - Assistant Professor)

Current Academic Appointments 1 [ type >> name of medical school ]

Current Academic Appointments 2 [ type >> name of medical school ]

Current Academic Appointments 3 [ type >> name of medical school ]

Current Academic Appointments 4 [ type >> name of medical school ]

Current Other/Hospital Appointments 1 [ type >> name ]

Current Other/Hospital Appointments 2 [ type >> name ]

Current Other/Hospital Appointments 3 [ type >> name ]

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SOCIETIES: Check national and international scientific and professional societies to which you belong

AAFPRS - American Academy of Facial Plastic and Reconstructive Surgery

AAOA - American Academy of Otolaryngic Allergy

AAO-HNSF - American Academy of Otolaryngology-Head and Neck Surgery

AAP - American Academy of Pediatrics

ABEA - American Broncho-Esophagological Association

ACS - American College of Surgeons

AHNS - American Head and Neck Society

AMA - American Medical Association

ANS - American Neurotology Society

AOS - American Otological Society

ARS - American Rhinologic Society

ASGO - American Society of Geriatric Otolaryngology

ASPO - American Society of Pediatric Otolaryngology

ARO - Association for Research in Otolaryngology

AADO - Association of Academic Departments of Otolaryngology

CSO - Canadian Society of Otolaryngology

RCS - Royal College of Surgeons

SUO-HNS - Society of University Otolaryngologists/Head and Neck Surgeons

Others - National or International (please give full name of society)

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GRANTS: If you have received any grant funding since completion of residency, please include information as outlined: Examples: (1) Triological Society Career Development Award, 8/1/2020 - 7/31/2022 (2) NIH K08, 7/1/2018 - 6/30/2023

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Civic, public or military positions

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PRACTICE: In which area do you spend the majority of your practice? Only one choice per column, please.

	Primary Focus	Focus #2 (IF APPLICABLE)	Focus #3 (IF APPLICABLE)
Administration	Administration Primary Focus	Administration Focus #2 (IF APPLICABLE)	Administration Focus #3 (IF APPLICABLE)
Allergy/Immunology	Allergy/Immunology Primary Focus	Allergy/Immunology Focus #2 (IF APPLICABLE)	Allergy/Immunology Focus #3 (IF APPLICABLE)
Bronchoesophagology	Bronchoesophagology Primary Focus	Bronchoesophagology Focus #2 (IF APPLICABLE)	Bronchoesophagology Focus #3 (IF APPLICABLE)
Facial Plastic & Reconstructive Surgery	Facial Plastic & Reconstructive Surgery Primary Focus	Facial Plastic & Reconstructive Surgery Focus #2 (IF APPLICABLE)	Facial Plastic & Reconstructive Surgery Focus #3 (IF APPLICABLE)
General Otolaryngology	General Otolaryngology Primary Focus	General Otolaryngology Focus #2 (IF APPLICABLE)	General Otolaryngology Focus #3 (IF APPLICABLE)
Head & Neck Surgery	Head & Neck Surgery Primary Focus	Head & Neck Surgery Focus #2 (IF APPLICABLE)	Head & Neck Surgery Focus #3 (IF APPLICABLE)
Laryngology	Laryngology Primary Focus	Laryngology Focus #2 (IF APPLICABLE)	Laryngology Focus #3 (IF APPLICABLE)
Neurotology	Neurotology Primary Focus	Neurotology Focus #2 (IF APPLICABLE)	Neurotology Focus #3 (IF APPLICABLE)
Otology	Otology Primary Focus	Otology Focus #2 (IF APPLICABLE)	Otology Focus #3 (IF APPLICABLE)
Pediatric Otolaryngology	Pediatric Otolaryngology Primary Focus	Pediatric Otolaryngology Focus #2 (IF APPLICABLE)	Pediatric Otolaryngology Focus #3 (IF APPLICABLE)
Rhinology	Rhinology Primary Focus	Rhinology Focus #2 (IF APPLICABLE)	Rhinology Focus #3 (IF APPLICABLE)
Sleep Medicine	Sleep Medicine Primary Focus	Sleep Medicine Focus #2 (IF APPLICABLE)	Sleep Medicine Focus #3 (IF APPLICABLE)
Part-Time Research	Part-Time Research Primary Focus	Part-Time Research Focus #2 (IF APPLICABLE)	Part-Time Research Focus #3 (IF APPLICABLE)
Full-Time Research	Full-Time Research Primary Focus	Full-Time Research Focus #2 (IF APPLICABLE)	Full-Time Research Focus #3 (IF APPLICABLE)

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As an applicant for candidacy for Active Fellowship in the Triological Society, I agree to adhere to the current standards of ethical conduct as defined by the American Medical Association [Latest Medical Code of Ethics News | American Medical Association (ama-assn.org)] and endorsed by the Triological Society.

Initial here

Date

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In order for your application to be considered complete, you must email the following by OCTOBER 1ST (beth@triological.org)

$50 fee in US dollars [our staff will email you to arrange payment]

Current Curriculum Vitae

Copy of specialty Board Certificate

Letters from Proposer and Seconder

A recent photograph (electronic preferred -- color or black & white -- no website photos). This photograph will be widely disseminated in the Candidate Credentials booklet, so resolution is important.

It is desirable for both the Proposer and Seconder to attend your Section business meeting and present you as their proposed candidate, however, at least one of them must attend your Section business meeting to speak on your behalf. In the event of an unforeseeable circumstance, and neither the Proposer nor Seconder can be present at the business meeting, those members present must unanimously agree to review your credentials without the benefit of the Proposer or Seconder. If the members do not unanimously agree to review your credentials without the Proposer or Seconder present, your application will be tabled. For International Candidates only: You will be a member of the section from which your proposers belong. If your 1st and 2nd proposers represent different sections, you may choose which section you wish to belong.

Deadline for Receipt of Materials Is October 1st

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NAME:

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Other Meetings (for international applicants only)

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OFFICE ADDRESS:

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CERTIFICATION INFO:

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BIRTH INFO:

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CONTACT INFO:

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OTHER INFO:

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PROPOSERS:

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PAPERS/PUBLICATIONS:

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MEETINGS: Number of national or international meetings other than Triological Society for which you registered and attended in the past five years

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TRAINING Please be sure to provide complete information

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ALL CURRENT APPOINTMENTS: Hospital and teaching (i.e. type - Assistant Professor)

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SOCIETIES: Check national and international scientific and professional societies to which you belong

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GRANTS: If you have received any grant funding since completion of residency, please include information as outlined: Examples: (1) Triological Society Career Development Award, 8/1/2020 - 7/31/2022 (2) NIH K08, 7/1/2018 - 6/30/2023

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Civic, public or military positions

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PRACTICE: In which area do you spend the majority of your practice? Only one choice per column, please.

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In order for your application to be considered complete, you must email the following by OCTOBER 1ST (beth@triological.org)