Committee on Interprofessional Education and Practice

Member Application

Question Title

* 1. Please provide your demographic information.

Name and Credentials

ACS Member ID (if applicable/known)

Institution/Organization

Business Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

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

Colorectal 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)

Question Title

* 3. What other ACS Committees are you applying to?

Question Title

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

Question Title

* 5. Please attach your CV or biosketch in PDF format.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 6. Please attach a statement of intent with a description of why you would like to serve as a member of this committee. A short explanation on your experience working with allied health professionals is preferred. Please also mention any accreditation experience, if applicable. (500 words or less)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File