APPLICATION FOR MEMBERSHIP

Type of Membership Application *

Active Physician Member

Associate Member (Allied Health Professional)

Accepted qualifications for Active Membership into the RMVS shall consist of, at least, one of the following:

a. Membership in the Society of Vascular Surgery.

b. Completion of an approved Vascular Surgical Fellowship or its equivalent (to be confirmed by a letter from the Fellowship Program Chairman).

c. The submission of 70 consecutive, reconstructive vascular surgical cases to the Membership Committee for consideration. The cases shall be dated and their initial outcome shall be recorded.

d. Certificate of Special Competence in General/Vascular Surgery.

e. Non-surgical physicians whose primary area of practice involves vascular health care delivery (to be confirmed by a letter from either their hospital’s Chief of Staff or Chairman of the Department).

Membership designated as Associate Member is open to physicians whose primary area of practice is other than vascular health care delivery. Associate Members will also include non-physicians who have distinguished themselves as dedicated providers in the field of vascular disease. Associate Members may attend the social, business and scientific functions of the Society but they shall be non-voting members of the Society and shall not hold office.

First Name *

Last Name *

Institution/Practice *

Mailing Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Date of Birth (mm/dd/yyyy) *

Spouse/Partner Name (if applicable)

CV/Resume *

Headshot/Profile Photo

SPONSOR INFORMATION

SPONSOR MUST BE A MEMBER OF THE ROCKY MOUNTAIN VASCULAR SOCIETY AND SUBMIT A LETTER OF RECOMMENDATION.

Sponsor 1 Full Name *

Sponsor 1 Email Address *

Letter of Recommendation (upload optional):

Additional documents (upload optional):

SPONSORS MAY ALSO MAIL COMPLETED LETTERS OF RECOMMENDATION TO:

Membership Committee
Rocky Mountain Vascular Society
1415 Commerical Ave, Suite 257,
Anacortes, WA, 98221
Telephone: 360-420-6906
www.rockymountainvascular.org

OR EMAIL TO: admin@surgicalcs.com