Committee on Resident Education: Committee Member Application

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* 1. Please provide your demographic information

Name and credentials *

ACS Member ID Number (if applicable/known)

Institution/Organization *

Business Address *

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

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* 2. Please select your specialty (select all that apply)

Colo-Rectal Surgery

OB/GYN

GYN Oncology

Neurosurgery

Neurosurgery – no cranial practice

OMFS

Ophthalmic Surgery

OTO

Neurotology

Sleep Medicine

Complex Pediatric Otolaryngology

Orthopedic Surgery

Orthopedic Spine

Ortho Sports Medicine

Ortho Joints

Ortho Trauma

Ortho Hand

Pediatric Surgery

Pediatric Trauma Surgery

Plastic Surgery

Plastic Hand

Plastic Cosmetic

Plastic Craniomaxillofacial

Burn Surgery

General Surgery

Acute Care Surgery

Trauma Surgery

Surgical Critical Care

Surgical Oncology -Complex Abdominal

Surgical Oncology – Breast

Transplant Surgery

Minimally invasive Surgery

Rural Surgery

Hand Surgery

Hospice & Palliative Surgery

Cardiothoracic Surgery

Cardiac Surgery

Thoracic Surgery / Oncology

Urology

Reconstructive urology

Vascular Surgery

Vein Surgery

Other (please specify)

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* 3. What other ACS Committees are you applying to? (you may apply up to 2)

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* 4. Please list other ACS committee(s) you currently serve on

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* 5. Please attach your CV or bio sketch (in pdf format)

PDF file types only.

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* 6. Please attach your statement of Intent: Describe why you want to serve as a member of the committee. (250 words)

PDF, DOC, DOCX file types only.

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