Please review all Requirements and Instructions before submitting.
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:

Fellowship Training
Date: Institution:
Position:

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

Certified by American Board of Surgery
Date: Certificate Number:

Certified by Other Specialty Board
Other Board Name: Certificate Number:
Date:

Recertification
Date: Certificate Number:

Fellow of American College of Surgeons?
Date:

Military Service
Branch of Service: Rank:
Dates:

Medical and Surgical Society Memberships
Academic and/or Teaching Appointments (Include dates)
Current Hospital Staff Appointments (Include dates)
Locations and Dates of Practice
What percentage of your practice is general surgery?
What is your primary specialty?
Other?
Publications (Use link at bottom of page to submit additional information)
Curriculum Vitae
Upload CV

Annual Meeting
Have you attended a SWSC Annual Meeting in the past?
Have you presented at a SWSC Annual Meeting in the past?
If so, what year?

Reference (Please submit one letter of reference from an Active Fellow of SWSC.)
SWSC Member Name: Email Address:
Phone Number:
Upload Letter of Reference

"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."

Questions and Inquiries may be directed to:

THE SOUTHWESTERN SURGICAL CONGRESS
5019 W. 147th Street
Leawood, KS 66224
Phone: 913-402-7102
Fax: 913-273-9940
Email: info@swscongress.org
Web: www.swscongress.org