INTERNATIONAL DERMATOLOGY RESIDENT E-MEMBER - Membership Application to join the Women's Dermatologic Society

	Category of Membership: INTERNATIONAL DERMATOLOGY RESIDENT E-MEMBER * = REQUIRED FIELDS. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

APPLICANT INFORMATION

MEMBERSHIP CATEGORY:

INTERNATIONAL DERMATOLOGY RESIDENT E-MEMBER:

All International Dermatology Resident E-Members receive electronic communications from the WDS but do not receive any materials in printed form. International Dermatology Resident E-Members shall be any physicians who are currently residents and who are certified in dermatology by a non-US or non-Canadian board or its licensing equivalent OR who satisfy educational or professional requirements approximately equivalent to certification requirements for the American Board of Dermatology or the Royal College of Physicians and Surgeons. International Dermatology Resident E-Members may include residents who do not reside in the US / Canada who meet membership requirements.
Membership Dues for International Dermatology Resident E-Member = Complimentary

APPLICATION DATE: *

Name: *


First *	Middle	Last *

Degree or Title: *

Date of Birth: *

* * *

Spouse’s Full Name:

WORK MAILING ADDRESS:

Company (If Applicable):

Address 1: *

Address 2:

City: *

State:

Zip:

Country: *

(If Other):

If you reside in a European country, you may apply for
Joint WDS-Eu/WDS membership. Click here to apply.

Phone: *


City/Area Code	Local Number *	Country Code *

Fax Number:


City/Area Code *	Local Number *	Country Code *

eMail: *

Citizenship: *

Practice: *

(If Other):

Preferred Mailing Address:

HOME MAILING ADDRESS:

Address 1: *

Address 2:

City: *

State:

Zip:

Country: *

(If Other):

If you reside in a European country, you may apply for
Joint WDS-Eu/WDS membership. Click here to apply.

Phone: *


City/Area Code	Local Number *	Country Code *

PRIVACY POLICY:

- You may publish my contact information on the WDS website to be viewed by members only *

- Do NOT publish my eMail address at all in print or on the WDS website *

- Do NOT publish my contact information in print or on the WDS website *

EDUCATION INFORMATION

Undergraduate Institution:

Institution: *

Degree: *

Year Completed: *

Medical or Graduate School:

Institution: *

Degree: *

Year Completed: *

Dermatology Residency Program:

Institution: *

Year Completed/Proposed Completion: *

Post-Dermatology Residency Fellowship (If Applicable):

Institution:

Year Completed/Proposed Completion:

Areas Of Specialization In Dermatology (If Applicable):

Institution:

Position Or Title (If Applicable):

CERTIFICATION

*
Dermatology Board Eligibility Year: *	Dermatology Board Certification Year: *
(use only if 'Equivalent Board' was selected) Board & Country


Dermatology Board Eligibility Year	Dermatology Board Certification Year
(use only if 'Equivalent Board' was selected) Board & Country


Dermatology Board Eligibility Year	Dermatology Board Certification Year
(use only if 'Equivalent Board' was selected) Board & Country

*** PLEASE NOTE:

If one of your 3 board choices as selected above is answered "Equivalent Board (Other Countries)", please describe in the text box below your dermatology equivalent board certification standards, which can include information about the examination, specific dermatology training, etc.

ADDITIONAL INFORMATION

Has your license to practice medicine in any jurisdiction ever been limited, suspended, or revoked
Have your privileges at any hospital ever been suspended, diminished, revoked or not renewed?
Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any local, state, or national medical society?
Are there any charges pending resolution by a Board of Medical Examiners in any state in which you have practiced medicine?
Have you ever been sanctioned by the Board of Medical Examiners?

SPONSORS

PROGRAM DIRECTOR’S NAME: *
PROGRAM DIRECTOR’S PHONE NUMBER: *

Are you currently in an ACGME approved program?
(Does not apply to all applicants who reside outside of the U.S.)

* Pre-Residency Fellows are not eligible for membership. Post-Residency Fellows may apply for Resident membership.

APPLICATION & FEES DETAILS

Incomplete applications will not be accepted.
The application fee and dues are waived for those applying for International Dermatology Resident E-Member Status.

MEMBERSHIP COSTS:

US $0 for the application fee
US $0 for the annual dues
TOTAL of US $0

Click the 'SUBMIT and PROCEED' Button Below and you will be taken to step 2 in the application process.

Additional Comments:

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*Note: Use of the name of Women’s Dermatologic Society and/or the Society logo on business or in any advertisement is prohibited.
**Membership applications are reviewed and approved by the Board of Directors twice yearly.