Full Name Address
City State Zip Code
Telephone (include area code) Fax E-mail
Date of Birth Place of Birth Citizenship Medical School Degree Year of graduation
Internship Year
Residency/Fellowship Training (indicate years)
Program Director
Military Experience Years Current Academic
Appointment
Current Location of Neurosurgical Practice
Principal Hospital Secondary Hospitals
Please account for years spent in neurosurgical practice at other than present location since completing
neurosurgical training
Sub-Specialty (if applicable)
Name California License Number Year
American Board of Neurological Surgery status: Certified Year
Date letter rec’d from American Board Eligible for exam
Other (Enclose copies of Certification or letter from American Board)
MEMBERSHIPS: yes no
Fellowship, American College of Surgeons
American Medical Association
American Association of Neurological Surgeons
Congress of Neurological Surgeons
California Medical Association
Other local or regional neurological society memberships:
I hereby apply for membership in the California Association of Neurological Surgeons and agree to abide by the published Bylaws. (Please call the CANS office if you would like to receive a copy of the bylaws.)
Signature of applicant Date
*This application for membership is endorsed by the following member of CANS:
Member signature Date
Printed last name
Contributions to the California Association of Neurological Surgeons are not tax deductible as charitable contributions; however, they may be tax deductible as ordinary and necessary business expenses.
Contact 916 457-2267 or emily@cans1.org if you need additional information.
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