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Membership Application Form

Application for Membership
 
Last Name * First Name * Middle Name
Date of Birth * Email *
Office Address
 
City * State * Zip *
Office Telephone * Office Fax *
Home Address
 
City * State * Zip *
Office Telephone *    
   
College and Post-Graduate Education
 
College * Post-Graduate Education * Date *
Internship
 
Internship * Location * Date *
Post-Graduate Residencies and Fellowship Training
 
Post-Graduate * Residencies * Fellowship Training *
Staff Appointments * (Length of Service, Staff Position, Title, etc.)
 
Academic Appointments * (Length of Services and Rank)
 
Medical Societies *
 
Board Certification, Specialty and Date
 
Certification * Specialty * Date *
Percent of Practice Related to Musculoskeletal Infections *
 
Name, Address and Phone Number of One Sponsor * (must be an active member of MSIS)
 

(Please note: The letters from each of your sponsors should be sent directly to the Chairman of the Membership Committee of MSIS )

Please submit your Curriculum Vitae with the following information: Training, Academic Contributions, Publications, Research, Presentations, Current Affiliations.

Upload CV
(CV must be in .pdf format )

Agreement

It is specifically agreed by the undersigned that in consideration MSIS's treatment of the entire contents of this application, as well as all inquiries or investigations made pursuant thereto as privileged and confidential material, and not subject to publication or public dissemination whether voluntarily, involuntarily or by operation of law, that 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. The undersigned further agrees that he/she will not cause or attempt to cause any public disclosure of the contents of any application with any applicant for Membership in the MSIS, or any proceedings of any Membership Committee or Board of Directors, whether said public disclosure be by operation of law or otherwise. Participation in one meeting every four years is required.

Signature of Applicant *   Date *
 

 

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