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Membership Application Form

Application for Membership
 
Last Name * First Name * Middle Name
Date of Birth * Email *
Address - Private
 
Street * City * State *
Country * Zip *
Country State Postal Code
Address - Public
 
Street * City * State *
Country * Zip *  
 
Country State Postal Code
Telephone
 
Public (Office) Private (Mobile)  
 
What % of your practice is dedicated to care of MSK infection? *
 
Name, Address and Phone Number of One Sponsor * (must be an active member of MSIS)
 

If not an active member of MSIS, your reference must be able to speak to your interest, participation and commitment to MSK infection, acceptable to the MSIS Membership Committee.

You must upload a CURRENT CV that includes the following information and enter the required data from your CV in the questions below.

CV Requirements All contents are considered public information.

  1. Education: including degrees achieved,
  2. Employment including title and Academic Appointments (including Rank) with Continuous timeline from high school to present
  3. Medical Licenses and Board Certifications, including issue date and expiration
  4. Medical and Professional Society participation, including Dates, Status Committee participation and leadership
  5. Medical Practice, including areas of clinical interest
  6. Academic activities, NUMERICALLY listed,

    1. Peer Review Publications
    2. Peer Review Presentations at International, National, State and regional meetings
    3. Invited lectures and Key note addresses at International, National, State and regional meetings
    4. Visiting Professorships
    5. Text Books
    6. Book Chapters
    7. Media/Video/Webinar
    8. research areas of activity
    9. research funding
Upload CV
(CV must be in .pdf format )

Agreement

The undersigned specifically authorizes MSIS to make whatever inquiries and investigation it deems necessary to verify the credentials, professional standing and moral and ethical character of the undersigned. MSIS will consider the contents of this application not marked as public, as well as information gathered from all inquiries or investigations made pursuant thereto as privileged and confidential material and will not publish or publicly disseminate that information unless required by low. The undersigned agrees that if accepted as a member, he/she will not cause or attempt to cause any public disclosure of private MSIS information including any application for Membership in the MSIS, any proceedings of any MSIS Committee, and/ any proceedings of the Board of Directors, unless required by law. Participation in one meeting Annual Meeting of the MSIS every four years is required for maintenance of Membership.

By typing your name on the Signature line you are making your commitment equal to writing your signature by hand. Your typed signature must match your entered name exactly.

Signature of Applicant *   Date *
 

 

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