Basic Information First Name * Last Name * Display Name * Professional Title Nominated By Seconded By Instructions & Information The FORUM is an association of elite, fellowship-trained female orthopedic surgeons who, as a charitable and educational group, seek the fullest possible integration of knowledge and research in advanced and emergent areas of science, ethics and technology, with particular respect to issues of interest to women. Accordingly, the FORUM was established to help us enhance women’s contributions to orthopedics, with emphasis on arthroscopic and sports medicine surgery via collaborative research and reporting; and to stimulate greater interest in orthopedics. We desire to contribute to orthopedics in a way that benefits the surgeons, the community and our common good. Further, we encourage all members to work individually and collectively as mentors, so that other women entering a career in surgery will learn the value of participating in orthopedics. Special Notes Your application must be completed to be considered; in addition please attach a recent copy of your CV. Please note your CV will not be considered in lieu of answering the questions. Submit your completed application and a copy of your CV to the FORUM member who is nominating you. You must complete the application in Excel and submit it electronically. Handwritten applications will not be accepted. Demographic, Practice & Education Information Email * Password * Confirm Password * Date of Birth Phone Number Degree Website URL ex: https://www.google.com Upload CV * Upload pdf, doc, or docx format only. Maximum allowed size is 2MB.| Reset Profile Photo Upload jpg, jpeg or png format only. Maximum allowed size is 2MB. | Reset Additional Information Work Information X Practice Name Address Line 1 Address Line 2 Country --Country-- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Island Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadin Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe State --State-- City --City-- Zipcode Phone Number Fax Number Website URL ex: https://www.google.com Add One More Work Information Home Information Address Line 1 Address Line 2 Country --Country-- Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Island Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadin Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia Zimbabwe State --State-- City --City-- Suburb --Suburb-- Zipcode Phone Number Fax Number Preferred Mailing Address * Office Home How long have you practiced in your current geographic area? Have your hospital privileges ever been suspended, revoked or not renewed? Yes No Have you ever been denied membership or renewal thereof, or been subject to disciplinary proceedings by any medical organization? Yes No Has your license to practice medicine in any jurisdiction ever been suspended or revoked? Yes No Current Hospital Staff Appointment(s) X Hospital Name + Add One More Hospital Past Practice Information X Previous Hospital / Business Name Address Date + Add One More Past Practice Educational History Medical School X Name of Institution Date + Add One More Medical School Residency X University / Hospital Type of Residency Date + Add One More Residency Fellowship X Name of Institution Type of Fellowship Date + Add One More Fellowship Teaching Appointment(s) Full-Time Faculty X Rank Institution Date of Appt. + Add One More Full-Time Faculty Clinical Faculty X Rank Institution Date of Appt. + Add One More Clinical Faculty Specialty & Medical Society Membership X Name Date + Add One More Membership Board Certification Applicants are required to be board eligible or certified in general orthopaedics by the American Board of Orthopaedic Surgeons (ABOS), the Canadian equivalent or the American Osteopathic Board of Orthopaedic Surgery. X Board Name Certificate Name Date + Add One More Board Certification Attestation * I agree that communications regarding my fitness for membership shall be made in confidence. I agree that if admitted as a Member of the FORUM, I shall abide by the By-laws and rules of the FORUM. I release from liability the FORUM and its officers, directors, members, agents and employees. The applicant being duly sworn, deposes and states that the information and responses provided in this application are true. Registration For * Free Lifetime Annual Please complete the CAPTCHA to verify you are not a robot. Submit Application
