Letter of Recommendation for Active or Corresponding Membership Step 1 of 2 50% Please report any problems with this form to [email protected]Sponsor Name* First Last Sponsor Email* Are you a member of AHNS?*YesNoFellow Name*Fellow Class*Which class is the fellow upgrading to?Active (within USA or Canada)Corresponding (outside of USA or Canada)In reference to this fellow's upgrade from Candidate to Active or Corresponding AHNS membership, would you be willing to comment on his/her professional competence and character?*YesNoIf not, why not?* How long have you known this fellow professionally?*Did you work with the fellow during his/her fellowship?*YesNoIn what capacity?*Fellowship DirectorFacultyResearch MentorIs the fellow's practice within the scope of the AHNS?*(e.g. actively engaged in diagnosis, treatment, and rehabilitation of patients with neoplasms and other diseases of the head and neck and the prevention of neoplasms and other diseases of the head and neck) YesNoHave you assisted the fellow, or has the fellow assisted you, at surgery?*YesNoDo you know of any adverse (reportable) action taken in the past or present or is pending which could limit or restrict the fellow's medical license or hospital staff privileges (including required supervision or monitoring) at any hospital?*If yes, please provide additional information in the comment box at the bottom of the application and/or attach appropriate documentation.YesNoWhat is your opinion as to the fellow's...*ExcellentGoodAverageFairPoorSurgical and clinical judgement?Professional and ethical conductDo you support this person's upgrade to Active or Corresponding AHNS membership?*Yes, without reservationYes, with reservation (add comment in below comment box)No (add comment in below comment box)Please add any comments or concerns regarding the applicant here.This information will only be seen by the AHNS office and Membership & Credentials Service Please upload any additional files/documentation if needed. Drop files here or Share:FacebookTwitterLinkedIn