Application for Active Group Membership

For physicians and surgeons in North America (U.S. and Canada)

Residents from all other countries should use the International application. For a full listing of requirements and benefits for Active Group Membership, please click here.

Group Membership Dues: One time initiation fee of $100 is waived; Annual Dues: $365.00.

*** Please note refunds will NOT be granted if application is not complete within 45 days of submission. ***

Personal Information

*First:	M.I.:	*Last:	Suffix:

Prof. Designations:	Gender:	Ethnicity:
	MaleFemale
Gender and Ethnicity are collected for statistical purposes only.

Date of Birth:	Place of Birth:	Citizenship:

Spouse First:	M.I.:	Last:	Suffix:

Contact Information

Business Information

*Position/Title:	*Business/Institution:

Address:	Address:

City:	State/Province:	Postal Code:	Country:

Telephone:	Fax:	E-mail:

Home Information

*Address:	Address:

*City:	*State/Province:	*Postal Code:	*Country:

*Telephone:	Fax:	*E-mail:

Communication Preferences

*Preferred mailing address for all ASGE mailings (GIE and Member Communication): HomeBusiness

*Preferred e-mail address for Scope and Member Alerts:HomeBusiness

*Preferred e-mail format:HTMLText

Sponsor Information

Sponsor

Full Name:	Institution:

Address:	Address:

City:	State/Province:	Postal Code:	Country:

Telephone:	Fax:	E-mail:

Actve or Senior Member of ASGE?YesNo		Applicant's Endoscopic Instructor?YesNo

Second Sponsor

Full Name:	Institution:

Address:	Address:

City:	State/Province:	Postal Code:	Country:

Telephone:	Fax:	E-mail:

Education

If any of the following information is not applicable, please indicate by entering NA in the required field.

*Institution	*Degree	*Date


*Medical	*Degree	*Date

Postgraduate Training

*Type	*Institution	*Program Dir.	*Inclusive Dates
*Internship

*Residency	*Institution	*Program Dir.	*Date

*Fellowship	*Institution	*Program Dir.	*Date

Other

Medical Licensure

*State/Country:	*Registry Number:

Endoscopic Training

*Institution:
*State/Country or Country
*Program Director:
*Inclusive Dates:

Board Certification

(If specialty board exam results are pending or if applicant is eligible to sit for specialty boards, please indicate.)

*Specialty Board: I.M G.I	Certificate Number:	*Date:
*Do you perform endoscopy? YesNo

Practice & Professional Information

Reasons for Joining the Society

(Check all that apply)
EducationAdvocacy/Legislation
ProfessionalismGIE
Discounted registration to DDWAccess to members only website
Other (please specify below)

Personal Interests (Check all that apply)

ASGE has formed 8 special interest groups (SIGs), and currently has one proposed SIG that is not yet active.

Please check any SIGs for which you would like more information. Ambulatory Endoscopic Centers
Capsule Endoscopy
Endoluminal Therapy for Esophageal Disease
Endoscopic Ultrasonography
Enternal Nutrition
Gastroesophageal Reflux Disease
Invention & Innovation
Small Bowel Endoscopy

Please check any of the following areas for which you would like to receive announcements of news or opportunities.
Legislative Updates
Practice Management Tips & Tools
Research Grant Opportunities
CME Opportunities
ASGE Special Events
ASGE Practice Guidelines & Technology Assessments
New ASGE Products
Natural Orifice Translumenal Endoscopic Surgery (NOTES™)

Group Membership Amount Due $350.00 per doctor:

Please note the initiation fee has been waived for those applying for the group membership program. I’m applying for group membership. I understand that at least 5 doctor’s from my practice must also apply for membership to have my initiation fee waived. Listed below are their names.

Fax Transmission Permission

By providing the fax number(s) and my signature below I authorize the American Society for Gastrointestinal Endoscopy (ASGE) and the American Society for Gastrointestinal Endoscopy Foundation to send me facsimiles, that may include education information, promotional materials, advertising, and other commercial materials considered to be official ASGE correspondence to its members, so that I can take full advantage of the various programs, services and member benefits offered by the American Society for Gastrointestinal Endoscopy.
NOTE: ASGE does not release, sell or grant permission for the use of membership fax or e-mail information to any outside company or organization. This contact information is solely for the use of ASGE. Once consent is provided it will remain in effect until a change in notification is made to ASGE. If you change organizations and/or obtain a new fax number you must complete and submit a new consent form. If you have multiple fax numbers all numbers must be listed. Only those numbers on file at ASGE will be used for fax correspondence.

Please list at least one fax number below that can be used to provide you with the latest association information.

Terms & Conditions

I authorize the American Society for Gastrointestinal Endoscopy to obtain information from societies, hospital staffs, members and any other source regarding this application and my qualifications for membership, which information, whether or not solicited by the Society, may be kept confidential by the Society.
*I certify that the above information is accurate.

*Enter your name in the box above to act as your signature.

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Application for Active Group Membership