First Name * Middle Name or Initial Last Name * Degree (MD or DO) * Mailing Address * City * State * Zip Code * Cell Phone * Primary Email * What are you currently? (Resident, Fellow, etc.) Year of Training Primary Specialty * Date of Birth * Provide any other information here to assist us as we process your application. A CV is required to complete your application. You can send it via email in PDF format to NRebel@aanos.org. Certification and Signature: I hereby certify that under penalty of law for perjury, the information I have provided in this application and supporting documents is all true and there is no ill intent or bad faith involved in my application for membership. I also understand that any falsification of reports, misrepresentation of material, significant omissions, dishonesty, forgery, and unethical practices will automatically render my application null and void. I moreover agree to comply with the Bylaws of the Academy and their rules and regulations. I agree to indemnify, release, and hold harmless the American Academy of Neurological and Orthopaedic Surgeons and its agents of any torts by reason of their acts or omissions regarding my application. I authorize full investigation of my application. My digital signature below is an authorization to anyone to release information you may request on me to help the Academy make an accurate assessment/evaluation of me. Type in your name in the field below. By doing so you agree this is a legal substitute for your signature. * Enter today's date. * If you are human, leave this field blank. Δ
