Dear Colleague:
Thank you for your inquiry concerning membership in the American Spinal Injury Association. This Application process consists of your completing this form and submitting a copy of your curriculum vitae to the Central Office. You will receive notification from the Central Office of receipt of your completed application, and a status report following the board's decision. |
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| Please select the category of membership for which you wish to apply: |
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| Membership Category Affirmation |
I have read all requirements for the membership category I selected and I assert
that I meet all requirements. |
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| PERSONAL INFORMATION |
| First Name |
Last Name |
Email Address |
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| Business Address |
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City |
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| State |
ZIP |
Country, if not USA |
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| Business Telephone |
Business Fax |
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| Home Address |
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City |
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| State |
ZIP |
Country, if not USA |
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| Home Telephone |
Home Fax |
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| Birthdate |
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Sex |
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Spouse's
First Name (if applicable) |
Spouse's
Last Name |
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| Citizenship |
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| LICENSURE INFORMATION |
| Description |
State |
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| Number |
Date of Conferral |
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| Has there ever been any action taken against your license? |
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| If yes, |
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| EDUCATION |
| Undergraduate Education |
Degree |
Year |
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Additional
Undergraduate Education |
Degree |
Year |
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| Graduate Education |
Degree |
Year |
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| Graduate Education 2 |
Degree |
Year |
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| Post Graduate Education |
Degree |
Year |
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| Internship |
Year |
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| Residency |
Year |
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| Fellowship Training |
Hospital |
Dates |
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Other
SpinalCord Injury Training |
Hospital |
Dates |
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Other
Spinal Cord Injury Training |
Hospital |
Dates |
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| Board Certified? |
If no, Board Eligible? |
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| Boards |
Date |
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| Hospital Appointments |
Location |
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| Classification |
Dates |
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| Hospital Appointments |
Location |
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| Classification |
Dates |
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| Hospital Appointments |
Location |
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| Classification |
Dates |
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| Hospital Appointments |
Location |
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| Classification |
Dates |
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| Have you ever been denied membership in any professional society? |
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| Have you ever been denied hospital or other institutional staff or admitting privileges? |
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| If yes, |
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| Professional Society Memberships |
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| Additional Relevant Information |
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| SPONSORS |
| Please list one (1) active member of the Association who will sponsor you for membership. This individual will be contacted by our Office to verify sponsorship. |
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Title |
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The deliberations of the Membership Committee and of the Board of Directors of ASIA on matters of membership are strictly privileged and confidential; are not subject to publication or public dissemination whether voluntary, involuntary, or by operation of law; and are not subject to discovery in connection with any court action, administrative proceeding or similar matter.
It is hereby agreed by the applicant that, in consideration of ASIA's treatment of the entire contents of this application, as well as the products or investigation made pursuant thereto, as privileged and confidential material, the applicant specifically authorizes ASIA and its representatives to make whatever inquiries and investigation they deem appropriate to verify the credentials, professional standing, and ethical character of the applicant. Clicking the "Send Application" Button constitutes acceptance of the above agreement. |
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Any questions about this process should be directed to:
Patricia Duncan
ASIA | Shepard Center Inc.
2020 Peachtree Road, NW
Atlanta, GA 30309
voice: 404.350.7591
email: pat_duncan@shepherd.org
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