IMPORTANT: Carefully read and answer all questions on this application.  If a question does not apply to your
specialty  and/or requirements, please indicate N/A.  Incomplete applications or documents that are specifically
requested but are not included or illegible, will be grounds for application disqualification.  Faxed applications
will not be accepted. 

APPLICATION:
L. NAME:                                                              F. NAME                                                     M.I__________  _______
PRIMARY SPECIALTY:                                                         SECONDARY SPECIALTY                                                   
ADDRESS:                                                                                                            
CITY                                                                        STATE                                                         ZIP CODE                              COUNTRY                                               DOB:                                     
PHONE:(             )                                              FAX:(              )_______________                  

MEDICAL SCHOOL                             INTERNSHIP
NAME:                                                                           NAME:                                                                          
CITY, STATE/COUNTRY:                                              CITY,STATE/COUNTRY                                       
DATES-FROM:                                 TO:                         DATES-FROM:                             TO:                  

   RESIDENCY TRAINING

1st   YEAR:                                                                                                                                                                                            
                                 ^{(HOSPITAL NAME)                                    (CITY,STATE/COUNTRY)                                       (DATES: FROM:TO)}
2nd YEAR:                                                                                                                                                                                            
                                 ^{(HOSPITAL NAME)                                    (CITY,STATE/COUNTRY)                                       (DATES: FROM:TO)}
3rd YEAR:                                                                                                                                                                                            
                                 ^{(HOSPITAL NAME)                                    (CITY,STATE/COUNTRY)                                       (DATES: FROM:TO)}
4th YEAR:                                                                                                                                                                                            
                                 ^{(HOSPITAL NAME)                                    (CITY,STATE/COUNTRY)                                       (DATES: FROM:TO)}
5th  YEAR:                                                                                                                                                                                            
                                  ^{(HOSPITAL NAME)                                    (CITY,STATE/COUNTRY)                                       (DATES: FROM:TO)}
6th  YEAR:                                                                                                                                                                                            
                                  ^{(HOSPITAL NAME)                                    (CITY,STATE/COUNTRY)                                       (DATES: FROM:TO)}
 
REQUIRED DOCUMENTATION CHECKLIST
THE INFORMATION LISTED BELOW MUST BE INCLUDED WITH THIS APPLICATION TO BE ELIGIBLE
FOR CERTIFICATION  FAXED INFORMATION WILL NOT BE ACCEPTED)

1. Copy of Current Biography /CV / Resume	6. Written Exam Fee(s) $500
2. Copy of Medical School Diploma	7. Oral Exam Fee(s)  $500
3. Copy of Internship Certificate(s)	8. Processing Fee(s) $250
4.  Copy of Residency Certificate(s)	9. Complete AANOS Membership Application (if not current member)
5.  Copy of CME totaling 150 hours	10. AANOS Membership Annual Dues $600 ( if not current member)

I hereby certify that under penalty of perjury of law, the information provided on this application are all-true and there is no ill intent or bad faith involved.  I also understand that any falsification of records, misrepresentation of material, significant omissions, dishonesty, forgery, and unethical practices will automatically render my application null and void.  I agree to indemnity, release and hold harmless the American Federation For Medical Accreditation  (AFMA) and its agents of  any torts by reason of their acts or omissions regarding my application.
I authorize full investigation of my application.  My signature below is an authorization to anyone to release information you  may request on me to help AFMA make an accurate assessment and/or evaluation of me.

                                                                                                                                                                      
                                                                   Signature                                                                                       date