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  • 1. SVS INTERNATIONAL MEMBERSHIP Eligibility: International Membership may be granted to surgeons residing outside of North America who have demonstrated knowledge and skill in the diagnosis and management of vascular disorders, by attainment of ONE of the following three criteria: 1. Successful completion of an ACGME-approved, Royal College of Physicians and Surgeons of Canada-approved, or equivalent vascular surgery training outside of the United States or Canada; OR 2. Certification in Vascular Surgery from the United States, Canada, or equivalent; OR 3. Surgeons whose clinical practice is dedicated primarily to vascular surgery. PLEASE NOTE: You must only meet and fill in information for ONE of the three criteria above. IMPORTANT DOCUMENTATION REQUIRED FOR COMPLETE APPLICATION All applicants must be sponsored by two (2) SVS members who will provide letters of support. This requirement can be waived in situations where Active or other International SVS members are not available to provide supporting letters. As an alternative, the SVS Membership Committee may consider substitution of a letter from the international applicant’s home society. The international applicant must be a member of the recognized vascular society for his or her country. The home society letter would attest to membership in good standing in the society, and would summarize the applicant’s qualifications for SVS membership. Give the names and addresses of (2) two Active Members of the Society for Vascular Surgery who agree to serve as sponsors and from whom you have requested letters of sponsorship. These letters must be received in order for the application to be considered complete. (1) Sponsor: ___________________________________________________________ ___________________________________________________________ __________________________________________________ (2) Sponsor: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Please do NOT include your CV with the application. I hereby submit my application for Active Membership in the Society for Vascular Surgery and the following data for consideration:
  • 2. Name _________________________________________________________________ (Last Name) (First Name) (Middle Name) Business Address _______________________________________________________ (Please include name of organization) _______________________________________________________________________ (Number and Street Address) _______________________________________________________________________ (City, State/Province, Zip Code, COUNTRY) Telephone (_____) - ____________Fax (____) -_____________E-mail______________ Home Address _________________________________________________________ (Number and Street) _______________________________________________________________________ (City, State/Province, Zip Code, COUNTRY) Telephone (_____) - _____________________ E-mail___________________________ PLEASE NOTE: You must only meet and fill in information for ONE of the three criteria below. Criterion 1: Training Successful completion of an ACGME-approved, the Royal College of Physicians and Surgeons of Canada approved, or equivalent vascular surgery training outside of the United States or Canada. A letter from your Program Director must accompany this application. Name of Program Director: _______________________________________________________________ Please check appropriate training completed: ___ACGME approved vascular surgery training program ___Royal College of Physicians and Surgeons of Canada-approved vascular surgery training ___Other (equivalent training to above) ________________________________ Place ____________________________________Dates___________________ Program Director _________________________________________________________ Indicate when you started active practice after residency/fellowship training: _____________________ Mo. /Yr. I hereby attest that the above information is accurate and I agree to abide by the Constitution and By-laws of The Society for Vascular Surgery.
  • 3. SIGNATURE _____________________________________________________, M.D. DATE ______________________________________________________________ Criterion 2: Certification Certification required in Vascular Surgery from the United States, Canada, or equivalent. Please check the appropriate certificate(s) you hold and provide certificate number: ___ American Board of Surgery Certificate in Vascular Surgery Certificate #_______________ ___ Royal College Certificate of Special Competence in Vascular Surgery Certificate #_______________ ___Other______________________________________________________________ Certificate #________________ Indicate when you started active practice after Residency/Fellowship Training: _____________________ Mo. /Yr. I hereby attest that the above information is accurate and I agree to abide by the Constitution and By-laws of The Society for Vascular Surgery. SIGNATURE _____________________________________________________, M.D. DATE ______________________________________________________________ Criterion 3: Surgeons whose clinical practice is dedicated primarily to vascular surgery For criterion #3, the Membership Committee will also take into account the following factors: • Contributions to vascular surgery education • Contributions to vascular surgery research • Membership in the American College of Surgeons • Participation in regional or local vascular societies CERTIFICATION Please check the appropriate certificate(s) you hold and provide certificate number: ____American Board of Surgery Certificate #_________________________ ____Fellow Royal College of Surgeons (Canada) Certificate #_________________________ ____Other (e.g. radiology, cardiothoracic) ____________________________________ Certificate #_________________________ PROFESSIONAL ACTIVITIES Current hospital privileges ____________________________________________________Dates______________ ____________________________________________________Dates______________ ____________________________________________________ Dates ______________ ____________________________________________________Dates ______________
  • 4. Past hospital privileges ____________________________________________________Dates______________ ____________________________________________________Dates______________ ___________________________________________________ Dates ______________ ____________________________________________________Dates ______________ Current medical school appointments School ___________________________________ Position _____________________ Date__________________ School ___________________________________ Position _____________________ Date__________________ Past medical school appointments School ___________________________________ Position _____________________ Date ___________________ School ___________________________________ Position _____________________ Date ___________________ Active Member of the American College of Surgeons (ACS Candidate Members are not eligible) Yes_______ no ___________ Active Member of regional vascular society Yes _______ no ___________ Name of society: _______________________________________________________________________ Practice limited to: ________________________________________________________ Designate % of practice devoted to the treatment of vascular disease: _______________ Indicate when you started active practice after Residency/Fellowship Training: _____________________ Mo. /Yr. Member of the following surgical and medical societies: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ LICENSURE List current licenses and numbers: _______________________________________________________________________
  • 5. _______________________________________________________________________ PUBLICATIONS, PRESENTATIONS AND RESEARCH GRANTS If no publications please state: _____________________ Attach separate pages listing publications. Only include papers that have been published or accepted for publication. Use the style of the Index Medicus and include authors’ names. Do not include abstracts. List all presentations that have been given during the past two years separately. For research grants, list the agency, number of years of funding, and the principal investigator. CASE LIST Complete the following table for a consecutive 12-month period during the past two years. A list of the cases is NOT an acceptable substitute for completion of this section. If more than one procedure is performed, only list the most major operation. Vascular experience for: _________________ to ________________ Month /year month/year Teaching Surgeon Assistant Assistant I Carotid endarterectomy ________ ________ ________ Cerebrovascular – great vessels ________ ________ ________ Thoracoabdominal aneurysm ________ ________ ________ Abdominal aortic aneurysm – elective ________ ________ ________ – ruptured ________ ________ ________ Aortoiliac (femoral) bypass or endarterectomy ________ ________ ________ Visceral/renal arterial reconstruction ________ ________ ________ Extra-anatomical bypass ________ ________ ________ Femoral popliteal (tibial) bypass – autogenous ________ ________ ________ – Prosthesis ________ ________ ________ Common femoral or profunda repair ________ ________ ________ Traumatic arterial (venous) repair ________ ________ ________ Other major vascular (specify on separate sheet) ________ ________ ________ Teaching Surgeon Assistant Assistant II Diagnostic angiography ________ ________ ________ Lower extremity angioplasty with/without stent ________ ________ ________ Upper extremity angioplasty with/without stent ________ ________ ________ Carotid angioplasty ________ ________ ________ Stent graft (e.g., endoluminal graft for AAA) ________ ________ ________ Thrombolysis ________ ________ ________ Diagnostic venography ________ ________ ________ Venous angioplasty ________ ________ ________ Visceral angioplasty with/without stent ________ ________ ________ Teaching Surgeon Assistant Assistant III
  • 6. Embolectomy (thrombectomy) ________ ________ ________ Vascular access ________ ________ ________ Thoracic outlet ________ ________ ________ IVC interruption ________ ________ ________ Major venous operations ________ ________ ________ Varicose veins ________ ________ ________ Amputations – major ________ ________ ________ – Minor ________ ________ ________ Sympathectomy ________ ________ ________ SUBTOTAL ________ ________ ________ GRAND TOTAL ________ ________ ________ I hereby attest that the above information is accurate and I agree to abide by the Constitution and By-laws of The Society for Vascular Surgery. SIGNATURE _____________________________________________________, M.D. DATE ______________________________________________________________

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