Application for Membership - Society of University Surgeons (SUS)

Membership Applications to the SUS must be completed and submitted by July 30, 2021. Please note, your application will not be considered complete until your Chair and both SUS Member Sponsors have submitted their recommendation forms. Applications and supporting documents will not be accepted after the cycle closes. Successful applicants will be reviewed by the SUS Membership Committee and recommended candidates will be presented for approval at the SUS Business Meeting, held during the 2022 Academic Surgical Congress.

Step 1 of 4

Eligibility Criteria
Will you be over 55 years old by February 2022?*
- Yes
- No
Do you currently occupy a faculty position in a university department of surgery and its affiliated teaching hospital?*
- Yes
- No
Do you have at least 15 peer reviewed manuscripts during your time as faculty?*
- Yes
- No
You may not be eligible for SUS Membership at this time. Before continuing this application, please contact SUS Member Services at [email protected] or by phone at (310) 986-6442 x 138 to discuss your eligibility.
You are not eligible for SUS Membership at this time. Please contact SUS Member Services at [email protected] or by phone at (310) 986-6442 x 138 to discuss your eligibility.

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Personal Information
Name*
First / Given Middle Name Last / Family Suffix
Degrees*
Date of Birth*
Please note, you must be 55 years old or younger by February 2022.
MM slash DD slash YYYY
Gender*
- Male
- Female
- Prefer Not to Answer
Institution Contact Information
Institution*
Academic/Institution Title*
Department*
Institutional Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email Address*
Assistant Name
Assistant Phone
Assistant Email
Alternate Contact Information
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone
Personal Email

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Department Chair and SUS Member Sponsor Recommendations
Recommendations are required:
- DEPARTMENT CHAIR:
  One (1) attestation that the application is accurate from the Chair of the department from which the candidate derives their appointment. The Chair may upload an optional recommendation.
- SUS MEMBER SPONSORS:
  Two (2) completed sponsor forms or recommendation from the nominating SUS Member Sponsors (1 form or recommendation each from 2 different SUS Sponsors).
NOTE: In order to meet the eligibility requirements, SUS Member Sponsors must be members in good standing. If an SUS Member Sponsor is unsure of their status, they should contact Member Services at [email protected] or call (310) 986-6442, ext 138, as soon as possible to confirm. Applicants who need assistance in identifying SUS members to serve as Sponsors are also encouraged to contact Member Services.

A link to the online recommendation form will be sent to the email addresses the candidate provides on the new member application. SUS Member Sponsors will be provided with a copy of the applicant's CV, and the Department Chair will receive a copy of the applicant's completed application. Please note that all information entered into this form will be sent to the Department Chair as part of the completed application file they will receive.
Sponsor 1 Name*
First Last
Sponsor 1 Email*
Sponsor 1 Phone
Sponsor 1 ID
Sponsor 1 Institution*
Sponsor 2 Name*
First Last
Sponsor 2 Email*
Sponsor 2 Phone
Sponsor 2 Institution*
Sponsor 2 ID
Department Chair Name*
First Last
Department Chair Email*
Department Chair Phone
Department Chair ID
Supporting Documents
Please be aware that the Save and Continue function does not work for document uploads. If you are going to save this application to finish later, please do not attempt to upload supporting documents. Attach the documents only when you are ready to submit the entire application.
Publications List (PDF only)*
Please upload your list of publications.
Accepted file types: pdf, Max. file size: 512 MB.
CV (PDF only)*
Please upload your CV.
Accepted file types: pdf, Max. file size: 512 MB.

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Funding Agency Name (NIH, DoD, PCORI, etc)	Award Title	Award Role (Your Role)	Award Annual Direct Dollars	Dates of Award (e.g. 2016-2017)

Leadership Role Type (National, International, Regional)	Organization or Society	Leadership Role	Leadership Year

Step 1 of 4

Eligibility Criteria

You may not be eligible for SUS Membership at this time. Before continuing this application, please contact SUS Member Services at [email protected] or by phone at (310) 986-6442 x 138 to discuss your eligibility.

You are not eligible for SUS Membership at this time. Please contact SUS Member Services at [email protected] or by phone at (310) 986-6442 x 138 to discuss your eligibility.

Personal Information

Institution Contact Information

Alternate Contact Information

Application History

Surgical Training

Additional Career Information

Grant Funding

Education Awards and Roles

Institutional Leadership

National, International, or Regional Leadership

Department Chair and SUS Member Sponsor Recommendations

Supporting Documents

Certifying Board	Date of Certification

Role Type	Description (e.g. Residency Program at {University Name}, {Society Name} CME Committee)	Year(s) in Role (e.g. 2017-present)

Unit or Program	Year(s)

Position	Year(s)