Category Archives: Applications

MEMBERSHIP APPLICATION:

The application must be completed and submitted to the Credentials Committee with a copy of the curriculum vitae and a letter of recommendation from a SIS member, the director of the fellowship program or a colleague.

                                       SCHEPENS INTERNATIONAL SOCIETY

NAME:_______________________________________________________________________________
First                              Middle                                                   Last

OFFICE ADDRESS:____________________________________________________________________
Street                                                                      Suite
_____________________________________________________________________________________

_____________________________________________________________________________________
City                                                 State/Country                                      Zip

OFFICE TELEPHONE:_______________________

OFFICE FAX_____________________________

E-MAIL______________________________

DATE OF BIRTH___________________________________

PLACE OF BIRTH_________________CITIZENSHIP________________YRS.

IN PRACTICE__________

MARITAL STATUS SINGLE___ MARRIED ___ SEX___ SPOUSE NAME_________________________

  1. LICENSURE Name of State/County/CountryDate Issued__________________________________________________________________________________________________

_____________________________________________________________________________________

  1. MD DEGREE OBTAINED

Date:__________From:________________________________________________________________________

  1. RESIDENCIES Name/Location of Institution                 Type of Service                               From-To (Mo & Year)

______________________________________________________________________________________

______________________________________________________________________________________

  1. FELLOWSHIP &/OR SPECIALIZED TRAINING IN RETINA Name/Location From-To (Mo & Year)

______________________________________________________________________________________

______________________________________________________________________________________

  1. ACADEMIC APPOINTMENT             Name of Medical School/Institution Position               From-To (Mo & Year)

_____________________________________________________________________________________

_____________________________________________________________________________________

  1. PRESENT HOSPITAL APPOINTMENTS Name/Location of Institution                           Position

_____________________________________________________________________________________

_____________________________________________________________________________________

Please submit a copy of your CV along with a letter of recommendation from the director of your fellowship training program or an associate or colleague currently in active practice:

Administrative Office
Patricia Wilson, Executive Secretary

10611 Piping Rock
Houston, TX 77042
Phone: (713) 798-3276
Fax: (713) 798-7848
E-Mail: psw@bcm.tmc.edu