DVVS Active/Candidate Membership Application
Membership Type Applying for:
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Name
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Date of Birth
mm/dd/yyyy
Office Address
City
State
ZIP
Telephone Number
E-Mail Address
Academic/University History
Dates attended college
College Degree
Medical School
Dates attended Medical School
Licensure/Registration/Certification
Specialty board certificates
Date and type of specialty
Surgical training (hospital)
Surgical training inclusive dates
Chiefs of service
Military service
Military service dates
Present hospital appointments
Present teaching appointments
Society membership
Sponsor
Bibliography
Bibliography file upload
Add attached sheet if necessary
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Program Director
Required for Candidate membership
Application submisison date
mm/dd/yyyy
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