New Member Application-SBVS

First Name

Last Name

Ethnicity/Background

Gender

Male

Female

Prefer not to answer

Preferred mailing address

Home

Work

Home Address

Work Address

Professional Degrees:

Practice Type

If Academic, select academic rank

Leadership Position

If other, please enter Leadership Position

Email

Phone

Membership Type (select one)

Active (Attending, practicing, retired, etc) -$200

Candidate (Resident, Fellow, trainee) - $50

Student - Free

Interest(s): select all that apply

I would serve as a potential speaker

Yes

No

If Yes, please let us know your preferred topics

Medical School and Year of Completion

Residency and Year of Completion

Fellowship and Year of Completion

Payment

All applications will be reviewed by the membership and executive committee. An invoice for your selected membership fee will be sent to the contact information listed on this application. You will receive a receipt when your payment has been processed.

Background/Security

A background/security check will be required to participate certain programs spearheaded by the society. By selecting the box below, you agree to a standard background check to be conducted by a 3rd party organization.

I agree to a background check as needed for participation in programs within the society.

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. I understand that false or misleading information in my application or interview may result in disqualification of this application. If my application is accepted, I pledge to abide by the bylaws, rules and regulations, and all policies and procedures set forth by this society. I hereby agree that if my application is not acted upon favorably, I will not hold the society or any of its officers or members legally responsible for this action.

Your Signature