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Applicant Information
First Name: Date of Birth (MM/DD/YY):
Middle Name: Place of Birth:
Last Name: Spouse Name (if applicable):
Email: Referred to Membership by (please list SWSC member if applicable):

Contact Information - Office
Institution: State:
Address (Line 1): Zip Code:
Address (Line 2): Phone:
Address (Line 3): Fax:
City:

Contact Information - Residence
Address (Line 1): State:
Address (Line 2): Zip Code:
Address (Line 3): Phone:
City: Fax:

Pre-Medical Education (Use link at bottom of page to submit additional information)
Institution: Degree:
Dates Attended:

Medical School Training (Use link at bottom of page to submit additional information)
Institution: Position:
Dates Attended: Degree:

Residency Training
Institution: Position:
Dates Attended: Degree:

Medical Licensure
State: License Number:
Date:
State: License Number:
Date:
State: License Number:
Date:

Anticipated American Board of Surgery Certification Date
Date:

Curriculum Vitae
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Reference (Please submit one letter of reference from an Active Fellow of SWSC.)
SWSC Member Name: Email Address:
Phone Number:
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"I hereby attest that the above information is true and that, if accepted, I will abide by all the Bylaws and Constitutions of The Southwestern Surgical Congress and that I accept the decision of the Council in consideration of this application as final and waive any right to appeal."
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Questions and Inquiries may be directed to:

THE SOUTHWESTERN SURGICAL CONGRESS
P.O. Box 24425
Overland Park, KS 66223
Phone: 913-402-7102
Fax: 913-273-9940
Email: info@swscongress.org
Web: www.swscongress.org