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:

OTHER INFO:

PROPOSERS:

PAPERS/PUBLICATIONS:

TRAINING:

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

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

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

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
Allergy/Immunology
Bronchoesophagology
Facial Plastic & Reconstructive Surgery
General Otolaryngology
Head & Neck Surgery
Laryngology
Neurotology
Otology
Pediatric Otolaryngology
Rhinology
Sleep Medicine
Part-Time Research
Full-Time Research

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.

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

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.

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