Online Membership Application

Membership Categories:

ACTIVE–maintain a license to practice medicine and be 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. Surgical Applicants must be Diplomats of a particular specialty board or have credentials that are equivalent to those issued by member boards of the American Board of Medical Specialties, the American Board of Otolaryngology, Plastic Surgery, or Surgery or OTHER EQUIVALENT CERTIFICATION BOARD. Additionally, all applicants must be Fellows of the American College of Surgeons (FACS), Fellows in the Royal College of Surgeons (FRCS) or similar credentials. Board certified oncologists may also become Active Fellows. All applicants must submit a Case Listing unless recently completed a fellowship from an approved AHNS Advanced Training Council Program within 5 years. ($400 annually)
UPGRADE TO ACTIVE FROM CANDIDATE–must have completed Fellowship training, submit documentation of ACS membership and a Case Listing (if completed any of the approved AHNS Advance Training Council Programs within 5 years, a Case Listing is not required) – $400 annually). ** ATC Graduates are automatically upgraded to Active membership and have up to three years upon graduation to complete become a Fellow of the American College of Surgeons (FACS), Fellow in the Royal College of Surgeons (FRCS) or obtain similar credentials requirements needed for Active membership.**
ASSOCIATE–must be a physician, dentist, or allied scientist who has demonstrated a special interest in the field of Head and Neck Oncology, but a significant portion of whose practice is concerned with managing patients with non-neoplastic diseases of the head and neck. ($100 annually)
CANDIDATE–shall be a trainee enrolled in, or a graduate of, an approved residency program in Otolaryngology, Plastic Surgery, or General Surgery or in a Fellowship Program approved by the Advanced Training Council. ($25 annually)
CORRESPONDING–must be a physician who specializes in the treatment of head and neck cancer, who by their professional associations and publications, would appear in the judgment of Council to be qualified to treat neoplasia and diseases of the head and neck. Must reside in a country other than the US or Canada ($100 annually)

Membership Category*
Please choose the category which you are qualified for:
- ACTIVE ($400 annually)
- UPGRADE TO ACTIVE FROM CANDIDATE ($400 annually)
- ASSOCIATE ($100 annually)
- CANDIDATE ($25 annually)
- CORRESPONDING ($100 annually)
First Name*
Middle Initial or Name
Last Name*
Suffix
Jr., Sr., II, etc.
Degrees
MD, etc.

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CV
Send your Curriculum Vitae to the AHNS Office at the address below OR upload the file now:
Accepted file types: pdf, doc, docx, odt.
Headshot
One copy of a 2" X 2"or passport size photo OR upload the photo now (Maximum acceptable image size is 300 pixels wide by 300 pixels high).
Accepted file types: jpg, png, gif.
Sponsoring Members
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.
AHNS Active Member Sponsor 1*
AHNS Active Member Sponsor 1*
AHNS Active Member Sponsor 2*
AHNS Active Member Sponsor 2*
Letters of Recommendation
Drop files here or
Accepted file types: doc, docx, pdf.
Case List
For Active members only. Please see below for full instructions
Accepted file types: pdf, doc, docx, xls, xlsx.
It is the applicant's responsibility to request two letters of recommendation from ACTIVE Fellows of the Society. International applicants may request letters from Active or Corresponding members. Please use the fields above to select your letter writers and they will be notified and will respond directly to the AHNS office.
Your $25 application fee, payable to the American Head and Neck Society
For Active applications -- please submit a case listing SIGNED by the Chief of Service or Department Chairman or Division Chair from each institution. Click here to download a sample case listing for format and requirements. Please note: If the Active applicant has completed a fellowship with any of the approved AHNS Advanced Training Concel programs, a case list does NOT need to be submitted.
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AHNS Membership Application Fee
If paying by check:
A check made payable to the American Head and Neck Society for the $25 application fee and mail to: American Head and Neck Society Membership Department 11300 West Olympic Boulevard, Suite 600 Los Angeles, CA 90064
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Credit Card*
American Express
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Visa
Card Number Expiration Date Security Code Cardholder Name
Credit Card Billing Address*
Please enter the Street Address, City and ZIP/Postal Code ONLY.
Same as Business/Institution Mailing Address
Street Address City ZIP / Postal Code Country
Only click the "Submit Application" button once. Double-clicking may result in duplicate applications and charges.

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Medical License Number	State, Province, Country	Date Issued	Board Certification Number	Specialty Board	Date Issued

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