Member Directory

Faculty Form

Faculty Form

    INSTRUCTIONS: The faculty form has been updated and simplified. Simply answer a few questions and upload an abbreviated CV. You cannot save the information – once you begin, it must be completed at one time.

    * Denotes Required Fields

    Contact Information



    Board Certification in*: Plastic SurgeryFacial Plastic SurgeryOtolaryngology/ENT

    Indicate if you are a Resident/Fellow/Medical Student*: ResidentFellowMedical Student

    Please choose your areas of participation:


    Faculty Acceptance of Responsibility:

    • I certify that the appropriate medical/patient releases for photography and the subsequent use in presentations has been obtained.
    • I certify that all copies of printed material has the permission of the author, and that my use of such material will not violate any copyright laws.
    • I understand that failure to comply may necessitate termination of my presentation.

    AV Equipment for PowerPoint Presentations:

    We will have all necessary equipment available for your PowerPoint presentation. All presentations are
    to be uploaded in advance. You will be emailed with instructions for uploading along with the due date.
    Please Note: If you choose to use another format on your own computer, please bring any necessary
    cables needed for a quick and easy connection to the equipment available in the program room.

    Which Organization do you belong to?* ASPSASAPSOther
    If other, please list equivalent organization here:*

    ASPS - ID#: 

    ASAPS - ID#:

    Upload CV here (doc, docx, pdf):*

    By typing your name in the box below, you are indicating your acceptance of all the above.

    Electronic Signature*:

    Click send button below to direct your form and CV directly to the Executive Office