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.
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EDUCATION
    Undergraduate School
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    Graduate School (if applicable)
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    Medical School
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    Residency Program
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    Hand Surgery Fellowship
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BOARD CERTIFICATION
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CURRENT PRACTICE
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CURRENT HOSPITAL AND SURGERY CENTER AFFILIATIONS
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    Primary Hospital
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    Other Hospital/Surgery Center 2
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    Other Hospital/Surgery Center 3
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    Other Hospital/Surgery Center 4
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    Other Hospital/Surgery Center 5
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    Other Hospital/Surgery Center 6
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RECOMMENDATION
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ADDITIONAL INFORMATION
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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.
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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.
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