Membership Application

DEADLINE: SEPTEMBER 15th

*Membership
Category

*Include Photo Image of Head Shot in .gif or .jpeg format

Active Membership
Corresponding Membership

*Specialty:

If other, please specify:

*Name:
*Credentials:
*Place of Birth:

*Date of
Birth :

Spouse or Domestic
Partner Name
(if applicable):

Office:

Home:

*Address 1:

*Address 1:

Address 2:

Address 2:

City, State, Zip:

City, State, Zip:

*Country:

*Country:

*Phone:

*Phone:

Fax:

Fax:

*E-mail:

E-mail:

Website:
*Member Signature:

*Date:

Bibliography of publications pertaining to the cervical spine. *Please attach.

Current research in cervical spine. *Please attach.

*Meeting attendance - Please list the recent CSRS meetings you have attended:
Year(s):

I was/am an author on a Paper/Poster presented at the following CSRS Annual Meeting(s)*:

*meetings within the last 5 years are eligible

Year

Meeting
Location (city/
state):

Title of Work:

Year

Meeting
Location (city/
state):

Title of Work:

Year

Meeting
Location (city/
state):ate):

Title of Work:

Year

Meeting
Location (city/
state):

Title of Work:

Year

Meeting
Location (city/
state):

Title of Work:

Three (3) Letters of Recommendation are required from Cervical Spine Research Society members.
Please list the names of the members from whom these will be sought:
*Sponsor 1:
*Sponsor 2:
*Sponsor 3:

Pre-Medical

School:
Degree:

Medical

Years:

School:
Degree:

Internship

Years:

School:
Years:

Residency

School:
Years:

Fellowship
(or other)

School:
Years:

Graduate
Education

School:
Years:

Professional
Specialty:
*Board Certification
(year):

*Name of Board:

According to AMA Guidelines, licensed to practice medicine in:

*Hospital or University Affiliations:

*Society Memberships:

To complete and submit this application electronically:

- Please upload CV and any other attachments as subsequent pages, including:
bibliography of publications, letters of recommendation, and/or current research
(.doc, .docx, PDF format). Please use .gif or .jpeg format for your photo.
- Please save file as one complete PDF document file
- Please use your last name in the file name when saving the new file
- Please E-mail new, combined file to csrs@aaos.org
Please make sure that all questions marked with a red asterisk * have been
answered.

DEADLINE: SEPTEMBER 15th

Questions? Contact us at csrs@aaos.org

Cervical Spine Research Society
6300 N River Rd, Ste 727
Rosemont, IL 60018-4226
Phone: 847-698-1628
Fax: 847-823-0536
Email: csrs@aaos.org
Website: www.csrs.org