Last)(First)(Middle

Candidate's Name______

(Last)(First)(Middle)

Office Address______Home Address______

______

______

______

Country ______Office Email ______Home Email ______

Office Phone ______Home Phone ______

Office FAX ______Home FAX ______

Birthdate______Birthplace______

Citizenship______Spouse's Name______

EDUCATION

Medical School______

Surgical Residency (Postdoctoral Training)

Hospital ______Location ______Dates ______

______

______

______

Pediatric Surgical Residency

Hospital ______Location ______Dates ______

______

BOARD CERTIFICATION AND/OR FELLOWSHIP

American Board of Surgery ____ Date ______/Certificate of Special Qualifications in Pediatric Surgery ____ Date ______

Other Boards (Thoracic, Urologic, Pediatric, etc.) and Country ______Date ______

______Date ______

FACS ____ Date ______FAAP(Surg) ____ Date ______

FRCS ____ Date ______FRACS ____ Date ______

PAPS Membership Application

Page 2

Does applicant confine 90% of his/her practice to the pediatric age group?YES ______NO ______

If the answer is "NO", then explain why you believe that the applicant should be eligible to become a member of the Pacific Association

of Pediatric Surgeons. (Use an additional sheet if necessary)

______

______

______

______

______

______

______

______

Date applicant began active practice of Pediatric Surgery______

Number of years in present community______

Licensure (State/Province and No.)______

Country______

Describe applicant's current professional activities under the following headings:

1. Academic Appointments:

______

______
______
______
______
______

1. Hospital Appointments:

______
______
______
______
______
______

1. Clinical Practice Outlet (Private, Group, Full-Time Hospital or Medical School, etc.):

______

______
______
______
______

PAPS Membership Application

Page 3

THIS APPLICATION MUST BE ACCOMPANIED BY:

1. Curriculum vitae with a bibliography (Published papers, also abstracts and presentations)
2. A current passport-size photograph
3. Exact inclusive dates of all training (include month beginning and month ending of each training assignment of both General

and Pediatric Surgery)

1. Letters of sponsorship are required from the candidate's training director in Pediatric Surgery, the sponsoring member, and

from two (2) other PAPS members in good standing

NOTE: Please attach additional sheets if more space is required

I HEREBY CERTIFY THAT I AM A MEMBER IN GOOD STANDING OF THE PACIFIC ASSOCIATION OF PEDIATRIC

SURGEONS AND THAT THE INFORMATION PRESENTED IN THIS APPLICATION FORM IS ACCURATE.

______

Signature of SponsorDate

FOR PAPS OFFICE USE

Application mailed by PAPS Secretary_____Date______

Application received by PAPS Secretary_____Date______

Sponsoring Member Letter Received_____Date______

Training Director Letter Received_____Date______

PAPS (1) Member Letter Received_____Date______

PAPS (2) Member Letter Received_____Date______

Approved by PAPS Board of Directors_____Date______

Approved by PAPS Membership_____Date______

Certificate Mailed to Applicant_____Date______