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Application for Membership
Chicago Society for Surgery of the Hand (CSSH)
If you wish to print this form out and mail it in, please
click here
.
Items marked by an asterisk (*) are essential to process your application and MUST be answered.
Applicant Name:
(*)
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Email Address 1
(*)
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Email Address 2
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Practice Name:
(*)
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Which address below do you prefer CSSH communications and inquiries?
(*)
Primary practice address
Home address
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Primary practice address
(*)
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Home address
(*)
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EDUCATION
Undergraduate School
Name:
(*)
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City and State:
(*)
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Degree:
(*)
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Date of Graduation:
(*)
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Graduate School (if applicable)
Name:
(*)
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City and State:
(*)
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Degree:
(*)
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Date of Graduation:
(*)
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Medical School
Name:
(*)
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City and State:
(*)
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Degree:
(*)
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Date of Graduation:
(*)
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Residency Program
Field of Training (Othapedic, Plastic, or General Surgery):
(*)
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Training Program
(*)
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City and State:
(*)
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Residency Program Director:
(*)
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Residency Dates:
(*)
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Hand Surgery Fellowship
Training Program:
(*)
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Program Director:
(*)
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Dates:
(*)
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BOARD CERTIFICATION
American Board of:
(*)
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Make selection
(*)
Board Eligible
Board Certified
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If certified, date of certification or recertification:
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If eligible, expected date of examination:
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Subspecialty Certificate in Surgery of the Hand?
(*)
Yes
No
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If certified, date of certification or recertification:
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Expected date of examination:
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CURRENT PRACTICE
Illinois State Medical License #
(*)
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Months currently practicing at same location
(*)
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Total surgical cases in past 12 months
(*)
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Total hand surgical cases in past 12 months:
(*)
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CURRENT HOSPITAL AND SURGERY CENTER AFFILIATIONS
How many hospital and surgery centers are you affiliated with
(*)
1
2
3
4
5
6
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Primary Hospital
Name:
(*)
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City and State:
(*)
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Other Hospital/Surgery Center 2
Name:
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City and State:
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Other Hospital/Surgery Center 3
Name:
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City and State:
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Other Hospital/Surgery Center 4
Name:
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City and State:
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Other Hospital/Surgery Center 5
Name:
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City and State:
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Other Hospital/Surgery Center 6
Name:
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City and State:
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If additional affiliations or information is needed, please enter it here.
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RECOMMENDATION
Name of an active member, per CSSH by-laws, who will support your application:
(*)
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How long have you known this active member?
(*)
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In what capacity is he/she familiar with you as a hand surgeon?
(*)
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ADDITIONAL INFORMATION
Have you ever been convicted of a felony?
(*)
Yes
No
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Please explain:
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Have you ever had your medical license restricted or revoked either through voluntary or involuntary action or surrender?
(*)
Yes
No
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Please explain:
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Have you ever had hospital membership restricted, revoked and/or denied?
(*)
Yes
No
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Please explain:
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Have you ever had any membership in any society and/or association restricted, revoked and/or denied?
(*)
Yes
No
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Please explain:
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Have you ever been censured by a state, medical society, and/or hospital?
(*)
Yes
No
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Please explain:
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Upon approval of your application, we will create an online account for you. You will be advised by email of your approval.
Please let us know the username and password you would like to use.
Requested Username
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Password
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Repeat Password
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AUTHORIZATION
In furtherance of my application for membership, I request and authorize the CSSH to evaluate and validate my credentials and information submitted for this application. I request and authorize any entity that may have information which they deem relevant to my fitness for membership, to provide such information to the CSSH.
I hereby waive any claim for damages, or otherwise, that I may have against any hospital, medical staff, medical organization, or individual who supplies information with the respect to my application, the CSSH, its officers, members, employees and agents of any act of omission or commission that they, or any of them, may take in good faith in connection with this application. I understand that the decision as to whether I qualify for membership vests solely and exclusively in the CSSH and that its decision 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.
Name signature
(*)
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