235 Cypress Street, Suite 200, Brookline, MA 02445

Secretary

Papri Sarkar, MD

Director

Brookline Dermatology Associates

235 Cypress Street, Suite 200, Brookline, MA 02445

617-277-0800 Phone

617-582-6060 Fax

Tax ID 04-6123550

DearColleague:

Thankyoufor your interestinbecomingamemberoftheNewEnglandDermatologicalSociety(NEDS). Tobegin theapplicationprocess,pleasesubmitanapplicationwhich isavailableasa hardcopy (attached)or onourwebsite witha$225applicationfeethatwillcoveryour dues for thefirstyearofmembership.Tocompleteyourapplication,you willalsoneedtosubmita letterofreferencefromActiveNEDSmember(templateattached).

TheNewEnglandDermatologicalSocietyoffersa50%discountonthefirstyear’smembershipdues for any personwhoapplies within oneyear ofcompletingresidencyorfellowshiptraining.TheSocietyalso offersa$50 rebateonmembershipduestoanymemberwho refersanewmemberto theSociety.

Your applicationwillbereviewedatthenextscheduledcouncilmeetingwhenallnecessary informationisreceived.

Ifyoushouldhaveanyquestions pleasefeelfreetocontactourAdministratorby telephoneat(781)434-7731ore-mail at .

Papri Sarkar,MD

Secretary,NewEnglandDermatologicalSociety

NEDSMembershipApplication

FullName:

Referredby:

HomeAddress:OfficeAddress:

Office Phone: OfficeFax:

Emailaddress:

DateofBirth://

PlaceofBirth://

CitizenofU.S.A.?

Ifno,citizenof

Howlonghaveyoupracticedatthepresentaddress?

Iherebyapplyforthefollowingmembershipcategory(checkone):

ActiveBoardcertifiedbytheAmerican BoardofDermatology

AssociateCompleted3years oftrainingindermatologybutnotboardcertified

AffiliateNon-dermatologists withdermatologyrelatedspecialty(i.e.researcher,pathology-trained

dermatopathologist)

AdjunctNursepractitioners andphysicianassistants whoworkunderthesupervisionofanactive

member

IfapplyingforActivemembership,year whenboard-certifiedindermatology:

Pleaselistotherboard-certifications:

Year:

Year:

Year:

Year:

IfapplyingforAdjunctmembership, pleasefilloutthis section:

Checkone:NursePractitioner:

PhysicianAssistant:

Please nameyoursupervisingDermatologist: LengthoftimeworkingwiththeaboveDermatologist:

Whatportionofyourpracticeis devotedto seeingdermatologypatients? %

Ifnot100%,howis yourothertimespent?

Trainingand Education(completeallthatapply)OR Attach your CV

1.Undergraduate:

Degree:

Yearcompleted:

School: Location:

2.Graduate:

Degree:

Yearcompleted:

School: Location:

3.AdditionalGraduate:

Degree:

School: Location:

4.InternshipandResidency:

Specialty: Yearcompleted:

Location:

Specialty: Yearcompleted:

Location:

Specialty: Yearcompleted: Location:

5.Fellowshiptraining:

Specialty: Yearcompleted:

Location:

Specialty: Yearcompleted:

Location:

Presenthospitalpositionsheld(donotlistcourtesyaffiliations):

Presentteachingpositionsheld:

MedicalSocietymemberships:

Areas ofinterest/expertise:

Publications:

ListoneActivememberwhowill sendlettersofendorsementonyourbehalf:

1.

Pleasereturn your application, payment and letter of endorsementtothefollowingaddress:

NEDSAdministrator

NewEnglandDermatologicalSociety

P.O. Box549127

Waltham, MA 02454-9127

781-464-4896 Fax

ApplicationFee:The$225applicationfeeis appliedtowardyourfirstyearofmembershipdues.Ifnot payingbycreditcard,pleaseforwardacheckpayableto“New EnglandDermatologicalSociety”tothe address above.

Signature:

Date:

TO:NEDS Administrator

New EnglandDermatologicalSociety

POBox549127

Waltham, MA 02454-9127

781-464-4896 Fax

DearAdministrator:

Iwouldliketo recommend

NameSuffix

formembershipintheNew

EnglandDermatologicalSociety. As awell-trainedandcompetentdermatologist, s/hewouldbean assettooursociety.

Sincerely,

Signature

PrintedName