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American Head and Neck Society
Application for Fellowship

Please read the Membership Guidelines before proceeding.

Please fill out the application as completely as possible. You will be required to mail in additional documents to support this application. For long text field, you may copy and paste the information from a word processor.

First Name: your given name
Last Name: your family name
Degrees: MD, etc
Office Address 1 : Hospital/Institution
Office Address 2 : Title/Department
Office Address 3 : Street Address
Office Address 4 : Street Address
Office City:
Office State:
US/Canada only  
Office ZIP/Postal Code:
Office Country: if outside US
Office Phone: xxx-xxx-xxxx
Office Fax: xxx-xxx-xxxx
Office Email:
Home Address:
Home Address:
Home City:
Home State:
Home ZIP/Postal Code:
Home Country:
Home Phone:
Home Fax:
Home Email:
Preferred Contact:
Place of Birth:
Date of Birth: MM/DD/YYYY
Citizenship Status:
Type of Practice:
How did you hear about the AHNS?:
Proposed Class of Fellowship :
(please read member guidelines for explanations)

-- $300 annually
$75 annually
-- $25 annually
-- $75 annually
Pre-Medical Education

Name of College or University, degrees, date of graduation
Medical School

Name of Medical School, date of graduation
Internship

Name of and location of hospital, type of service, dates
Licensure

Name of state, province or country, date license issued
Residency

Name and location of Institution, type of service
Fellowships







-- Iowa City IA





-- Pittsburgh PA
-- New York, NY
-- Cincinnati OH
-- Houston TX


Univ of Alberta, Edmonton, AB, Canada
:

Post-Residency Experience

Name and location of Institution, type of service
Board Certification

Name of specialty board and date
FACS, FRCS or Equivalent

Surgeons Only. Date of Induction
Past and Present Hospital Appointments

Name and location of hospital, medical staff position and dates
Academic Appointments

Name and location of institution, staff position and dates
Medical/Surgical Society Memberships

Name of medical or surgical societies of which you are a member
Name and Address of Sponsors

The two names should be ACTIVE members who have agreed to propose you for membership.
For active fellowship, one must be from your community.
For corresponding applicants, sponsors may be either active or corresponding members.
Postgraduate Courses

Name of medical school or sponsoring body, specialty or subjects, dates
Contributions to Medical Literature
You must enter the Security Code below to submit this application.

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AHNS, 11300 W. Olympic Blvd, Suite 600, Los Angeles, CA 90064
ph: (310) 437-0559 / fx: (310) 437-0585
admin@ahns.info