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AMERICAN COLLEGE OF SURGEONS ELIGIBILITY QUESTIONNAIRE

NOTICE: IF YOUR WISH TO REQUEST FELLOWSHIP APPLICATION BLANKS, COMPLETE AND RETURN THIS QUESTIONNAIRE. DO NOT SEND PAYMENT WITH THIS FORM, AS THIS IS NOT A FORMAL APPLICATION.

I. CERTIFICATION:

A. BY A MEMBER BOARD OF THE AMERICAN BOARD OF MEDICAL SPECIALTIES:

American Board of ________________________________ Date _________________________

B. BY THE ROYAL COLLEGE OF PHYSICIANS AND SURGEONS (CANADA):

Specialty Division in Surgery _________________________ Date _________________________

II. LICENSURE STATUS:

Do you have a full and unrestricted license to practice medicine and surgery in the state/ province from which you would be submitting your application? _______ Yes _______ No

III. HOSPITAL APPOINTMENTS:

A. Do you have a current active appointment on the surgical staff at a hospital? _____ Yes _____ No

B. Do you have a current established practice as a specialist in surgery? _______ Yes _______ No

C. Are you in practice at your intended permanent location? _______ Yes _______ No

IV. LENGTH OF PRACTICE:

Have you completed two years of uninterrupted surgical practice at one location

after completion of all formal training? _______ Yes _______ No

PLEASE TYPE OR PRINT THE INFORMATION BELOW.

NAME ______________________________________________ DATE __________________________

STREET ADDRESS ____________________________________________________________________

CITY ________________________________________STATE _______________ ZIP ______________

OFFICE TELEPHONE __________________________________FAX____________________________

YOU MAY PROVIDE DETAILS TO ANY QUESTIONS THAT WERE ANSWERED "NO":

_____________________________________________________________________________________

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