Deadline for Receipt of Materials Is October 1st Survey

OTHER INFO:

Home street address

Home city

Home state

Home zip

Home country

Spouse name

Send Society correspondence & publications to home or office?

Hobbies/Interests

PROPOSERS:

Proposed by

Seconded by

PAPERS/PUBLICATIONS:

Number of papers you have presented at Triological Society meetings within the last five years

Number of papers you have presented at other national meetings within the past five years

Total number of scientific publications, as first author, in peer reviewed journals

TRAINING:

College 1 [ name >> years attended >> degree ]

College 2 [ name >> years attended >> degree ]

PostGrad 1 [ advanced degree (excluding medical school) ]

PostGrad 2 [ advanced degree (excluding medical school) ]

Medical School [ name >> years attended >> degree ]

Internship 1 [ where >> years >> type ]

Internship 2 [ where >> years >> type ]

Residency 1 [ where >> years >> type ]

Residency 2 [ where >> years >> type ]

Fellowship 1 [ where >> years >> type ]

Fellowship 2 [ where >> years >> type ]

ALL CURRENT APPOINTMENTS: Hospital and teaching (i.e. type - Assistant Professor)

Current Academic Appointments 1 [ type >> name of medical school ]

Current Academic Appointments 2 [ type >> name of medical school ]

Current Academic Appointments 3 [ type >> name of medical school ]

Current Academic Appointments 4 [ type >> name of medical school ]

Current Other/Hospital Appointments 1 [ type >> name ]

Current Other/Hospital Appointments 2 [ type >> name ]

Current Other/Hospital Appointments 3 [ type >> name ]

NATIONAL MEETINGS: Number of national meetings other than Triological Society for which you registered and attended in the past five years

2014 - 2018

SOCIETIES: Check national and international scientific and professional societies to which you belong

AAFPRS - American Academy of Facial Plastic and Reconstructive Surgery

AAOA - American Academy of Otolaryngic Allergy

AAO-HNSF - American Academy of Otolaryngology-Head and Neck Surgery

AAP - American Academy of Pediatrics

ABEA - American Broncho-Esophagological Association

ACS - American College of Surgeons

AHNS - American Head and Neck Society

AMA - American Medical Association

ANS - American Neurotology Society

AOS - American Otological Society

ARS - American Rhinologic Society

ASGO - American Society of Geriatric Otolaryngology

ASPO - American Society of Pediatric Otolaryngology

ARO - Association for Research in Otolaryngology

AADO - Association of Academic Departments of Otolaryngology

RCS - Royal College of Surgeons

SUO-HNS - Society of University Otolaryngologists/Head and Neck Surgeons

Other (please give full name of society)

GRANTS: Have you received any grant funding and, if so, please give details including name of project(s), type of grant(s) received, and name or organization from which grant funding was received

Civic, public or military positions

PRACTICE: In which area do you spend the majority of your practice? Only one choice per column, please.

	Primary Focus	Focus #2 (IF APPLICABLE)	Focus #3 (IF APPLICABLE)	Focus #4 (IF APPLICABLE)
Administration	Administration Primary Focus	Administration Focus #2 (IF APPLICABLE)	Administration Focus #3 (IF APPLICABLE)	Administration Focus #4 (IF APPLICABLE)
Allergy/Immunology	Allergy/Immunology Primary Focus	Allergy/Immunology Focus #2 (IF APPLICABLE)	Allergy/Immunology Focus #3 (IF APPLICABLE)	Allergy/Immunology Focus #4 (IF APPLICABLE)
Bronchoesophagology	Bronchoesophagology Primary Focus	Bronchoesophagology Focus #2 (IF APPLICABLE)	Bronchoesophagology Focus #3 (IF APPLICABLE)	Bronchoesophagology Focus #4 (IF APPLICABLE)
Facial Plastic & Reconstructive Surgery	Facial Plastic & Reconstructive Surgery Primary Focus	Facial Plastic & Reconstructive Surgery Focus #2 (IF APPLICABLE)	Facial Plastic & Reconstructive Surgery Focus #3 (IF APPLICABLE)	Facial Plastic & Reconstructive Surgery Focus #4 (IF APPLICABLE)
General Otolaryngology	General Otolaryngology Primary Focus	General Otolaryngology Focus #2 (IF APPLICABLE)	General Otolaryngology Focus #3 (IF APPLICABLE)	General Otolaryngology Focus #4 (IF APPLICABLE)
Head & Neck Surgery	Head & Neck Surgery Primary Focus	Head & Neck Surgery Focus #2 (IF APPLICABLE)	Head & Neck Surgery Focus #3 (IF APPLICABLE)	Head & Neck Surgery Focus #4 (IF APPLICABLE)
Laryngology	Laryngology Primary Focus	Laryngology Focus #2 (IF APPLICABLE)	Laryngology Focus #3 (IF APPLICABLE)	Laryngology Focus #4 (IF APPLICABLE)
Neurotology	Neurotology Primary Focus	Neurotology Focus #2 (IF APPLICABLE)	Neurotology Focus #3 (IF APPLICABLE)	Neurotology Focus #4 (IF APPLICABLE)
Otology	Otology Primary Focus	Otology Focus #2 (IF APPLICABLE)	Otology Focus #3 (IF APPLICABLE)	Otology Focus #4 (IF APPLICABLE)
Pediatric Otolaryngology	Pediatric Otolaryngology Primary Focus	Pediatric Otolaryngology Focus #2 (IF APPLICABLE)	Pediatric Otolaryngology Focus #3 (IF APPLICABLE)	Pediatric Otolaryngology Focus #4 (IF APPLICABLE)
Rhinology	Rhinology Primary Focus	Rhinology Focus #2 (IF APPLICABLE)	Rhinology Focus #3 (IF APPLICABLE)	Rhinology Focus #4 (IF APPLICABLE)
Sleep Medicine	Sleep Medicine Primary Focus	Sleep Medicine Focus #2 (IF APPLICABLE)	Sleep Medicine Focus #3 (IF APPLICABLE)	Sleep Medicine Focus #4 (IF APPLICABLE)
Part-Time Research	Part-Time Research Primary Focus	Part-Time Research Focus #2 (IF APPLICABLE)	Part-Time Research Focus #3 (IF APPLICABLE)	Part-Time Research Focus #4 (IF APPLICABLE)
Full-Time Research	Full-Time Research Primary Focus	Full-Time Research Focus #2 (IF APPLICABLE)	Full-Time Research Focus #3 (IF APPLICABLE)	Full-Time Research Focus #4 (IF APPLICABLE)

As an applicant for candidacy for Active Fellowship in the Triological Society, I agree to adhere to the current standards of ethical conduct as defined by the American Medical Association and endorsed by the Triological Society.

Initial here

Date

In order for your application to be considered complete, you must email or mail the following by OCTOBER 1ST (beth@triological.org --- Triological Society, 13930 Gold Circle Suite 103, Omaha, NE 68144

$50 fee [credit card payments can be made at www.triological.org (click on the Membership tab and then click on the Credit Card Dues Payments icon-- use member ID #1111) OR checks payable to the Triological Society]

Current Curriculum Vitae

Copy of specialty Board Certificate

Letters from Proposer and Seconder

A recent photograph (electronic preferred -- color or black & white -- no website photos). This photograph will be widely disseminated in the Candidate Credentials booklet, so resolution is important.

It is desirable for both the Proposer and Seconder to attend your Section business meeting and present you as their proposed candidate, however, at least one of them must attend your Section business meeting to speak on your behalf. In the event of an unforeseeable circumstance, and neither the Proposer nor Seconder can be present at the business meeting, those members present must unanimously agree to review your credentials without the benefit of the Proposer or Seconder. If the members do not unanimously agree to review your credentials without the Proposer or Seconder present, your application will be tabled.

Deadline for Receipt of Materials Is October 1st

Please check below the Triological Society meetings for which you have registered and attended. Within the previous five years, you must have attended a minimum of three meetings of national societies of the specialty, one of which must be a Triological Society meeting.

NAME:

OFFICE ADDRESS:

CERTIFICATION INFO:

BIRTH INFO:

CONTACT INFO: