Title:* -Select- Mr Mrs Ms Dr Prof MD First Name:* Middle Initial: Last Name:* Email address:* Date of Birth:* Password:* Re enter Password:* Specialty:* -Select- Orthopaedic Surgery Infectious disease physician Podiatry Other Would you like to show your profile on Find a physician map? Other Specialization:* Profile Photo: (Please upload only jpg, jpeg, png image. Maximum Size: 2MB) Reset Work Information(Public) (It is recomended to enter work location details as that will be used to display your profile on the map and search results.) Practice Name: * Phone Number Work address Line 1 * Work address Line 2 * Country: * -- Select -- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Aruba1 Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern territories Gabon Gambia Georgia Germany 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Grenadin Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe State * -- Select -- City * -- Select -- Zip Code * Home Information(Private) Mobile Number Home address Line 1 * Home address Line 2 * Country: * -- Select -- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Aruba1 Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern territories Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Isla Honduras Hong Kong Hungary Iceland India Indonesia Iran Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Other Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadin Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe State * -- Select -- City * -- Select -- Zip Code * What % of your practice is dedicated to care of MSK infection? * Score:* Please have your Reference Letter emailed directly to Marcy (msis.marcy@gmail.com) 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 (i) Peer Review Publications (ii) Peer Review Presentations at International, National, State and regional meetings (iii) Invited lectures and Key note addresses at International, National, State and regional meetings (iv) Visiting Professorships (v) Text Books (vi) Book Chapters (vii) Media/Video/Webinar (viii) research areas of activity (ix) research funding Curriculum vitae:* (N.B: Please upload only PDF. Maximum Size: 5MB) 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 :* Are you authorize MSIS to make your profile appear on the website?* Yes No