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THE ACADEMY OF ANESTHESIOLOGY

NOMINATION OF MEMBERSHIP

Name of Proposing Member:

Date:

When proposing a nominee for active membership in the Academy, please keep in mind the following:

• That the nominee should present a paper at an Academy meeting. *
• That the nominee and spouse should attend at least one meeting of the Academy as a guest of an established member. **
• That the proposing member should be present.
• That nominees may not be present the year they are considered for membership. ***
• That all data be submitted to the Secretary in sufficient time prior to the Annual Meeting to permit consideration of the nomination by the Executive Committee.

*   If nominee has already done so:

   Nominee presented paper before the Academy titled:

(Title of presentation)

**   If nominee has already attended:

   Nominee attended meeting of the Academy with spouse on:

(date)

***   By vote of the Academy March 25, 1990, nominees will not be considered for membership if attending that meeting.

* * * * * * * * * * * * * * * * *

                            Nomination for active membership in the Academy

Nominee’s Name:  

Spouse’s Name:

Home Address:

Present Position:

Where/Address:  

Number of years in the practice of Anesthesiology: 

Please send your reasons for nominating this physician for membership, i.e. background, contribution to the specialty, bibliography, curriculum vitae, etc. Use separate pages as necessary.