| Membership Information | |
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| First Name: | |
| Middle: | |
| Last Name: | |
| Degree: |
MD DO Other: |
| Work Information | |
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| Affiliation/Institution: | |
| Address: | |
| City: | |
| State: | |
| Province: | |
| Zip/Postal Code: | |
| Country: | |
| E-mail: | |
| Phone: | |
| Fax: | |
| Home Information | |
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| Address: | |
| City: | |
| State: | |
| Province: | |
| Zip/Postal Code: | |
| Country: | |
| Phone: | |
| Fax: | |
| Member Preferences | |
|---|---|
| Preferred Mailing Address: |
Note: your member directory listing will be the address where you receive your mail. |
| May we send you AWS materials by: |
fax |
| Status with the American College of Surgeons: | |
| Board Certified: |
If yes, enter mm/dd/yy |
| Academic Position: | |
| Practice Type: | |
| Surgical Specialty (select up to 3): |
Bariatric Breast Cardiothoracic Colorectal Dermatology Endocrine General Surgery Gynecology Minimally Invasive Neurosurgery Nutrition Oncology Ophthalmology Orthopedic Otolaryngology Pediatric Surgery Plastics/Reconstruction Transplant Trauma/Critical Care Urology Vascular Other Specify: |
| I am interested in volunteering to serve on an AWS committee: | |
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I am interested in serving as a colleague resource and/or
mentor: |
Yes - Academic Yes - Private Practice Yes - Resident/Student |
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AWS often nominates women to serve in various positions within
other medical organization. Please check all organizations
below of which you are a member: |
American College of Surgeons American Medical Association American Medical Women's Association American Surgical Association Association for Academic Surgery Association for Surgical Education Association of Program Directors in Surgery Association of VA Surgeons Society of University Surgeons |
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