Academy of Anesthesiology - Member Application

Membership

Feb 20

2019 Meeting

Member Application

* Name of Proposing Member

When proposing a nominee for active membership in the Academy, please keep in mind the following:

That the nominee should present a paper at an Academy meeting. *
That the nominee and spouse should attend at least one meeting of the Academy as a guest of an established member. **
That the proposing member should be present.
That nominees may not be present the year they are considered for membership.***
That all data be submitted to the Secretary in sufficient time prior to the Annual Meeting to permit consideration of the nomination by the Executive Committee.

*** By vote of the Academy March 25, 1990, nominees will not be considered for membership if attending that meeting.

If nominee has already done so: Nominee presented paper before the Academy titled: (Title of presentation)

If nominee has already attended: Nominee attended meeting of the Academy with spouse on: (Date)

* Nominee's First Name

* Nominee's Last Name

* Spouse's First Name

* Spouse's Last Name

* Home Address

* City

* State

* Zip Code

* Present Position

* Where is the present position held?

* Office Address

* City

* State

* Zip Code

* Phone

* Email

* Number of years in the practice of Anesthesiology

* Please upload your reasons for nominating this physician for membership, i.e. background, contribution to the specialty, bibliography, curriculum vitae, etc.

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