Online Membership Application

Please complete all required fields (indicated by an *) before attempting to submit. Once you submit your membership application, you should go to www.ficsonline.org/aanos to pay the $450 application fee and dues through the International College of Surgeons website. ICS processes credit card transactions on behalf of the AANOS. Indicate “AANOS application fee” in the payment purpose field.

First Name *

Middle Name or Initial

Last Name *

Title (MD or DO) *

Business Street Address *

Business City *

Business State *

Business Zip Code *

Business Phone *

Business FAX

Home or Cell Phone Number

Primary Email *

Secondary Email

Primary Specialty *

Secondary Specialty

Date of Birth *

1. Have you ever had your medical license, pharmacy, or DEA license reclassified, suspended, restricted or revoked? *

Yes

No

2. Have you had a physical, emotional, alcohol/substance abuse problem that may impair your judgement or performance? *

Yes

No

3. Have you been subject to a disciplinary action by a medical society, hospital, or board? *

Yes

No

4. Have your privileges, medical or surgical, been revoked or curtailed by any hospital? *

Yes

No

If the answer to any of the previous 4 questions was YES, you must provide a detailed explanation in the field below. You may also send your explanation via email to info@aanos.org if more space is required.

Your participation in the Academy is important.

Are you willing to present abstracts for the Annual Scientific Meetings?

Yes

No

Are you willing to submit articles for Publication in the Journal of Neurological & Orthopaedic Medicine and Surgery (JONOMS)?

Yes

No

I agree to attend one Annual Scientific Meeting at least every three years in order to maintain my membership status. *

Yes

No

The following documentation is required with your application. You can send these documents in the mail or you may email them in PDF format to Nick@aanos.org. Please check each of the boxes below to indicate you understand the requirements. *

Current Curriculum Vitae (Must include Medical School name and location, as well as any post graduate training programs you completed – Internship, Residency, Fellowship, etc.)

Copy of Medical School Diploma

Copies of all Training & Residency Certificates

Two (2) Letters of Recommendation (Must be from colleagues who are of the same specialty. One should preferably be from the Head of the Department at a hospital where you have or have had privileges. Letters must be on letterhead which includes contact information, dates of practice observation and signature. Letters must come directly from referee.)

Copies of all State Medical License(s)

Copies of DEA & Pharmacy License(s)

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. *

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