Membership Application

Name:

Email:

Country of residence:

Nationality:

Specialty:

Institution:

Position:

Years in practice:

If a resident - PGY year:

Medical school and year of graduation:

States/country where you are licensed:

What board certifications do you have:

Interests in international humanitarian surgery:

Prior international experience:

Prior international surgical experience:

Have you worked at or do you know of a hospital in a developing country that would benefit from a volunteer surgeon or anesthesiologist? Please give details.

What length of experience are you interested in?

Please forward completed application to sharon@humanitariansurgery.org