ࡱ> PSO'` nbjbjLULU w2.?.?` $PFD,}3hDDD\;O [))))+*x.x2$4hM7"37;"3D\73 |D\) ) 6&5(D 1epH%^')M30}3'@7785(75(c lccc"3"3A Rccc}3  AMERICAN COUNCIL OF ACADEMIC PLASTIC SURGEONS Membership Application 500 Cummings Center, Suite 4550 Beverly, MA 01915 Phone: 978-927-8330 Fax: 978-524-0461  HYPERLINK "http://www.acaplasticsurgeons.org/" http://www.acaplasticsurgeons.org/ I hereby apply for ASSOCIATE Membership Associate members shall be individuals who are teaching faculty not yet certified by the ABPS or the RCPS(C), other educators and plastic surgery residency program coordinators committed to plastic surgery education and who have a special interest in the purposes and activities of the Council. Associate members are encouraged to attend functions of the Council but shall not be eligible to vote and/or hold office in the Council. Date:  FORMCHECKBOX  I am a Plastic Surgery Residency Program Coordinator Name: DOB: (Last) (First) (MI) (MM/DD/YYYY) Office Address: (Institution) (Address) (City) (State) (Zip) Phone: Fax: Home Address: (City) (State) (Zip) Phone: E-mail: Position : Institution Date appointed Program Director Name: (Required, must be an Active member of ACAPS) American Board Certification or Canadian Fellowship Status: if applicable Surgery: Date Board Plastic Surgery: Date Board Other Specialty: Date Board Plastic Surgery Recertification: Date Professional Education and Training: Medical School Date of Graduation Residency / Fellowship Training (list all surgical training): if applicable 1. Institution Dates Position Chief of Service 2. Institution Dates Position Chief of Service 3. Institution Dates Position Chief of Service 4. Institution Dates Position Chief of Service Membership in Organizations (Please check next to appropriate organizations) if applicable  FORMCHECKBOX  Fellow, American College of Surgeons Date  FORMCHECKBOX  American Society of Plastic Surgeons Date  FORMCHECKBOX  American Association of Plastic Surgeons Date  FORMCHECKBOX  Plastic Surgery Research Council Date  FORMCHECKBOX  American Society for Surgery of Hand Date  FORMCHECKBOX  American Assn. for Hand Surgery Date  FORMCHECKBOX  American Burn Association Date  FORMCHECKBOX  American Society for Aesthetic Plastic Surgery Date *PLEASE ATTACH A CURRENT COPY OF YOUR CURRICULUM VITAE. I certify that the information provided in this application is correct to the best of my knowledge. I agree to abide by the rules and regulations of the ACAPS if elected to membership. Signed: Date:     &./EFGHbfgxy ýtkd]d hz|hR[< hz|h-<hQhYZaJhchc0JaJjhchT>UaJ hcaJjhcUaJ h7SaJ haJ haJ h-<aJ hcaJ hiFaJh7Sh7SCJ aJ h-<5CJ\aJ h7SCJh7S5CJ\aJhx5CJ\aJhI5CJ\aJ!/FGgy# $ ( ) *  ; ]gdn= @&]gdn= $]a$gd"]gd2; $]a$gd2; $@&]a$gd.`m   " # $ 5 ' ( 0 : @ C R ` d ~  tj_W_W_W_W_hn=CJaJhf'Jhn=CJaJh7Shn=>*aJjhA h^UaJ h^aJjh^UaJh^h^aJ hn=>*aJ hn=aJh"hYZ5\aJhYZB*aJphhQeBhQeBB*aJphh.HhQeB5B*aJphh[B*CJaJphhIh[h[h[5 hz|hA"  ; I J O k r y     . 3 4 5 G M W X i j ɿɸɱ֞yh.Hhn=CJaJh.Hhn=aJ hn=5aJh00hn=>*aJh00hn=aJh7Sh00>*aJ h-<>*aJ h00>*aJh7Sh-<>*aJ h7S>*aJ h-<aJhn=CJaJh7Shn=>*aJ hn=>*aJhf'Jhn=CJaJ hn=aJ-; < J k l 4 5 6 X ]`gdn=]gd2; @&]gd. ]`gd"]gdn= #&,345MPW_wzSTabcr}ܵʇzz h|>*aJ h|aJh[h-<6aJ h[aJh7Sh-<>*aJ h~>*aJ h7S>*aJ h~aJ h-<aJ h"aJh-<6\aJh[6\aJh[5\aJh-<5\aJh"]5\aJh"5\aJhn=5\aJ0 56`abc~ ]`gd2;]gd2; @&]gd.01NOmn#j @&]gd.]gd2;]gd|$/7<EM`l}"#$23478P^chj¹˯ haJ h2;aJ h*aJjChA hA UaJ hA aJjhA UaJh[6\aJh[5\aJh95\aJh-<5\aJh"5\aJ h|>*aJ h7S>*aJ h-<aJ h|aJ2jkyz{|}~    5:;<JKLMNOPǺǰǺǰǺǰzt hHyaJjhA hA UaJjhA hA UaJj+hA hA UaJ hA aJjhA UaJ h*>*aJ haJ h-<aJ h2;aJ h*aJjhA hA UaJhA hA aJjhA hA UaJ-;MNOBCD`bcefhiklmngd7 @&]gd.]gd2;PWv{ #BGLMNOP"'Bݱݡ}w hxaJh-<5\aJhn=5\aJh"5\aJh*5\aJjohA hA UaJjhA hA UaJ h2;aJ h*aJjhA hA UaJ hA aJjhA UaJ h*>*aJ hS&aJ h-<aJ,BCLT[_`acdfgijmnhPojhPoU h*>*aJ h-<aJ h9aJ=0&PP:p7SBP/ =!"#$%@h 6 00PBP/ =!"#$% DyK yK ^http://www.acaplasticsurgeons.org/yX;H,]ą'ctDeCheck4tDeCheck4tDeCheck4tDeCheck4tDeCheck4tDeCheck4tDeCheck4tDeCheck4tDeCheck4H@H Normal1$7$8$H$_HaJmH sH tH DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List <&< Footnote Reference4@4 =lHeader  !4 @4 =lFooter  !6U@!6 c Hyperlink >*B*phVY2V . 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