Step 1 of 4 25% Eligibility CriteriaWill you be over 55 years old by February 2024?* 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. Personal InformationName* First / Given Middle Name Last / Family Suffix Degrees* Date of Birth*Please note, you must be 55 years old or younger by February 2024. MM slash DD slash YYYY To better support our membership, please provide us the following information. The confidentiality of our membership is paramount; all responses will be deidentified and will only be used for internal audit, research, and program development purposes.Gender* Male Female Non-Binary Prefer Not to Answer How would you describe yourself?*Select all that apply Alaska Native or Native American Asian Black or African American Hispanic or Latinx Middle Eastern or North African Native Hawaiian or other Pacific Islander White Not listed Prefer not to answer Institution Contact InformationInstitution* Academic/Institution Title* Department* Institutional Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone*Email Address* Administrative Support Name Administrative Support PhoneAssistant Email Alternate Contact InformationHome Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Cell PhonePersonal Email Application HistoryHow many times have you applied for SUS Membership?*My First Time!1234Year(s) in which you applied. Surgical TrainingResidency Institution* Are you Board Certified?* Yes No Certifying BoardsCertifying BoardDate of Certification Specialty* Cardiac Surgery Cardiac/Thoracic Surgery Colon and Rectal Surgery Endocrine Surgery General Surgery Hepatobiliary Surgery Laparoscopic/MIS Neurosurgery Ophthalmology Orthopedics Otorhinolaryngology Pediatric Surgery Plastic/Reconstructive Surgery Surgical Oncology Thoracic Surgery Transplantation Trauma/Acute Care Surgery Urology Vascular Surgery Subspecialty Additional Career InformationSuccessful applicants are expected to meet at least two of the four criteria in the categories listed below, and documented within the application and/or CV. GRANT FUNDING: Evidence of extramural research funding of at least $100,000 per year for a current or previous three year period. On the CV, delineate percent effort devoted to each grant and funding received. EDUCATION: Details for at least one (1) of the following: (a) Departmental (or higher) teaching award as a faculty member, (b) Director or Associate Program Director of a resident, medical student, or fellowship training program, (c) Chair of National or International Committee focused on education, or (d) other major leadership role in education, including international educational projects or initiatives. INSTITUTIONAL LEADERSHIP: Director of a major, independent functional unit (i.e. SICU) or multidisciplinary program, Division Chief or other major named administrative position (e.g Chair of your institution’s IRB or quality committee) within the past five years. NATIONAL, INTERNATIONL, OR REGIONAL LEADERSHIP: Evidence of leadership activities at a national, international, or regional level within the past five years, such as: Chair of a National Committee, Member of the Executive Council or an Officer of a national surgical or scientific organization, inclusion on a extramural grant review panel, editor or associate editor of a major journal, leadership of a global surgical initiative, or editor of a major textbook. Grant FundingPlease write N/A if not applicable.Extramural Research Funding*Funding Agency Name (NIH, DoD, PCORI, etc)Award TitleAward Role (Your Role)Award Annual Direct DollarsDates of Award (e.g. 2020-2021) Education Awards and RolesEducation Awards*Please write N/A if not applicable.Education Award NameAward Year(s) e.g. 2020-2021 Education Roles*Please write N/A if not applicable.Role TypeDescription (e.g. Residency Program at {University Name}, {Society Name} CME Committee)Year(s) in Role (e.g. 2019-present) Institutional LeadershipWithin the past five years have you served in at least one (1) of the following roles:* Director of a major, independent functional unit (i.e. SICU) or multidisciplinary program, Division chief, or another major named administrative position (i.e. chair of your institution’s IRB or quality committee). None of the above Directorships*Please write N/A if not applicable.Unit or ProgramYear(s) Chief or other Positions*Please write N/A if not applicable.PositionYear(s) National, International, or Regional LeadershipPlease write N/A if not applicableLeadership Roles*Leadership Role Type (National, International, Regional)Organization or SocietyLeadership RoleLeadership Year Department Chair and SUS Member Sponsor RecommendationsRecommendations 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 use our Public Member Directory feature or 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 PhoneSponsor 1 IDSponsor 1 Institution* Sponsor 2 Name* First Last Sponsor 2 Email* Sponsor 2 PhoneSponsor 2 Institution* Sponsor 2 IDDepartment Chair Name**Note: Department Chair cannot be the same person as one of your Sponsors. First Last Department Chair Email* Department Chair PhoneDepartment Chair IDSupporting DocumentsPlease 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.
