THE NEW ENGLAND HAND SOCIETY

New England Hand Society
Membership Application for Physicians

PART I: PERSONAL DATA
Name:
Business address:
Home address:
Work phone:
Home phone:
Fax:
Email address:
Preferred mailing address:



You automatically qualify for membership in the NEHS if you have received your Certification of Added Qualifications in Surgery of the Hand. Please provide the date of certificaiton and attach a photocopy of your CAQH.
Date of Certification of CAQH:

PART II: PROFESSIONAL QUALIFICATIONS
1. Practice Description
Current practice location(s):
Percent caseload in hand/upper extremity:
 %
Previous practice location(s):
2. Credentials
Undergraduate Institution:
Degree/date:
Medical School:
Degree/date:
Internship:
Dates:
Residency:
Dates:
Fellowship:
Dates:
Board Certification(s):
Date(s):
State Licensure:
Number:
Date:
3. Teaching Affiliations
Names and dates:
4. Presentations/Publications/Teaching Experience (last 4 years)
Names and dates:
5. Membership in Professional Organizations
Names and dates:
6. Letter of Recommendation
Submit two letters of recommendation from physician members of the NEHS.
Name and address:
Name and address:

PART III: DISCIPLINARY ACTION(S)
Are you currently under investigation by any professional organization or licensing board?



Has your medical license ever been suspended or revoked?



If you answered yes to either of the above, please provide a detailed explanation:

I attest that the aforementioned replies are true and accurate.

If I become a member, I hereby agree to comply with the Constitution and By-Laws of the New England Hand Society, and further agree to pay all dues and assessments promptly.
Signature:
Date:

PLEASE SUBMIT YOUR MEMBERSHIP APPLICATION BY SEPTEMBER 30, if you wish it to be considered at the Annual Business Meeting of the NEHS in December of that year.

PLEASE MAIL TO:
Samuel Scott, M.D.
100 Foder Road, Suite 307
So. Portland, ME 04106
207-773-9729
Fax: 207-774-6501
drscott@maine.rr.com

Please attach a copy of your most recent CURRICULUM VITAE with this application.

Thank you for your interest in the NEHS.


Andrew E. Caputo, M.D.
President

David M. Bass, M.D.
Vice President

David Ring, M.D.
Secretary and Treasurer

Samuel Scott, M.D.
Membership Chairman

Mary Drake
Therapist Liasion