Thank you for your interest in applying for the ASE Independent Academic Medical Center Working Group. Please complete the form below by Wednesday, June 5 and the ASE Membership Committee will follow up with all applicants in June. Independent Academic Medical Center Working Group Name(Required) First Last Degree(s) Institution Email(Required) Current Role(Required) Attending Physician (MD, DO) Scientist (PhD) Physician in Training (Residents, Fellows) Medical student Nurse Coordinator Advanced Practice Provider (Nurse Practitioner, Physician Assistant) Not Listed If not listed, please describe your current role. What practice setting do you work in?(Required) Community-based Community-based university affiliated University-based Military-based Not Listed Osteopathic Recognition Prefer not to disclose If not listed, please describe what practice setting you work in. Are you a private/community surgeon actively engaged in training medical students / surgical residents or fellows?(Required) Yes No Are you willing to participate in this working group aimed to serve surgical educators who are not directly employed by academic institutions?(Required) Yes No
