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Application Type:

Name:

Date of Birth:

Birth Place:

Business Information

Address:

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City:

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Phone:

Fax:

Email:

Home Information

Address:

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Professional Qualifications

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Residency:

Degree:

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Hand Fellowship:

Fellowship Director:

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Board Certification:

Hospital Affiliation:

Hand Cases Last Year:
Any investigations pending?
Any license revocations or restrictions?
Any felony convictions?

In furtherance of my application for membership in the American Association for Hand Surgery (AAHS), I hereby authorize the evaluation and validation of my credentials by AAHS in accordance with and subject to the rules and procedures of the AAHS.

I request and authorize any hospital, medical staff, medical organization or individual who may have information (including, but not by way of limitation, medical records, patient records, and reports of committees) which they deem relevant to my fitness for membership in AAHS to provide such information to AAHS.

I hereby release from liability and waive any claim for damages that I may have against AAHS, its officers, directors, members, employees and agents for any acts that they may perform in good faith in connection with my application, and any hospital, medical staff, medical organization or individual supplying information with respect to my application.

I understand that the decision as to whether I am qualified to be submitted to AAHS membership for election rests solely and exclusively in the AAHS Board of Directors, and that its decision is final.

I further understand that my election to membership rests solely and exclusively in the membership of AAHS, and that its decision is final.

I attest that the information presented in this application is truthful and accurate.

NOTE: By Typing "AGREE" into the text box, you are attesting to these statements and this constitutes your signature.

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