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ASMBS International Membership Application (Surgeon/Physician)
All entries must be completed. Missing or incomplete entries will delay the processing and approval of your application. Contact ASMBS Member Services at membership@asmbs.org for questions or assistance.
Contact Information
Name
Email
example@example.com
Demographics
Company/Institution/Hospital Name
Address
Street Address
Suite/Department
City/Town/Province/Region
State / Province
Postal / Zip Code
Country
Phone Number
Select Your Membership Category
International Member (Licensed medical doctors or osteopaths practicing outside of the United States. Eligible applicants should demonstrate scholarly interest in the treatment of obesity and a commitment to the long-term care of persons with obesity.)
International Candidate Member (A Fellow or Student in training with the intention of specializing in Bariatric Surgery)
If you are unsure, check this box and the ASMBS membership manager will assist you.
Board Certification
Please specify as requested in the textbox below the checkboxes
Certified by U.S. Surgical Board (please specify):
Certified by Royal College of Surgeons (country):
Certified by Other National Surgical Board (country and name):
Fellow of:
Not applicable/In Progress
Other
Add surgical board, country, etc. here:
Licensure
Has your license to practice medicine or surgery ever been limited, suspended, revoked, or subject to disciplinary action in any country?
Yes
No
Have you been the subject of any disciplinary action by a medical society or hospital staff within the last five years?
Yes
No
Have you ever been convicted of a serious crime (fraud, corruption, or equivalent under your country’s laws)?
Yes
No
If yes to any of the above, please attach an explanation and supporting documents.
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Authorization
If needed, I authorize the ASMBS to obtain information from societies, hospital staff, members, and other sources regarding this application and my qualification for membership, which will be kept confidential by the ASMBS.
Yes
No
To the best of my knowledge the information on this application to be accurate.
Yes
No
Date
-
Year
-
Month
Day
Date
Curriculum Vitae (CV)
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Copy of Board Certification/License
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Upon submission of a completed application, the application is sent to the ASMBS Membership Team for review. It can take approximately 4-6 weeks for approval. Pending members are eligible for the reduced member rate for all educational meetings and symposiums. The American Society for Metabolic and Bariatric Surgery prohibits discrimination against any member or any applicant for membership because of race, color, gender, national or ethnic origin, age, religion, disability, sex, or any other characteristic protected under applicable federal or state law.
Payment Instructions
After submitting this application, ASMBS will contact you with a link to pay your membership dues based on the established tiered pricing structure.
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