Schepens International Society

MEMBERSHIP APPLICATION:

The application must be completed and submitted to the Credentials Committee with a copy of the curriculum vitae and a letter of recommendation from a SIS member, the director of the fellowship program or a colleague.

SCHEPENS INTERNATIONAL SOCIETY

NAME:_______________________________________________________________________________
First Middle Last

OFFICE ADDRESS:____________________________________________________________________
Street Suite
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City State/Country Zip

OFFICE TELEPHONE:_______________________ OFFICE FAX_____________________________

E-MAIL______________________________DATE OF BIRTH___________________________________

PLACE OF BIRTH_________________CITIZENSHIP________________YRS.IN PRACTICE_________ _

MARITAL STATUS SINGLE___ MARRIED ___ SEX___ SPOUSE NAME_________________________

1. LICENSURE Name of State/County/Country Date Issued ____________

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2. MD DEGREE OBTAINED

Date:__________From:________________________________________________________________________

3. RESIDENCIES Name/Location of Institution Type of Service From-To (Mo & Year)

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4. FELLOWSHIP &/OR SPECIALIZED TRAINING IN RETINA Name/Location From-To (Mo & Year)

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5. ACADEMIC APPOINTMENT Name of Medical School/Institution Position From-To (Mo & Year)

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6. PRESENT HOSPITAL APPOINTMENTS Name/Location of Institution Position

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Please submit a copy of your CV along with a letter of recommendation from the director of your fellowship training program or an associate or colleague currently in active practice:

Administrative Office
10611 Piping Rock
Houston, TX 77042
Phone: (713) 798-3276 • Fax: (713) 798-7848