VSA Membership Application

Fields with * are required

CONTACT INFORMATION
Name * : 
Title: 
Mailing Address * : 
Check this box if Billing Address and Mailing Address are the same.
Billing Address * : 
Home Phone * : 
Work Phone * : 
Work Ext: 
Fax: 
Email * : 
Alternate Email: 
Date of Birth:  / / (mm/dd/yy)
Gender: 

 

HOSPITAL / INSTITUTION / PRACTICE
Practice Type: 
Hospital / Institution / Practice * : 
Medical Education: 
Internship: 
Licensed to practice in * : 
Certification by ABA * : 
Other Certification: 
URL: 

 

MEMBERSHIP CATEGORIES & ELIGIBILITY REQUIREMENT
Active Doctors of Medicine or Osteopathy who are licensed to practice medicine and who have successfully completed a training program in anesthesiology, accredited by Accreditation Council for Graduate Medical Education (ACGME) or equivalent organizations, or the American Osteopathic Association (AOA). $350
Affiliate
  • Anesthesiologist residing outside U.S.
  • Anesthesiologists in service of U.S. Gov't, including V.A.
  • Research scientist interested in anesthesiology
  • Physician not in clinical practice of anesthesiology
$50 
Retired Free
Resident Physician in full-time training in Anesthesiology residency in U.S.
Location: 
Graduation Date:  / /
Free
Student Individual in full-time training in U.S. Medical School.
Location: 
Graduation Date:  / /
Free

 

PAYMENT INFORMATION
Card Type:  American Express Discover MasterCard Visa
     
Name printed on card: 
Card Number: 
Security Code: 
Expiration Date:  /
Card Address: 
Card Zip Code: 
   
Electronic Signature
I certify that I meet the above criteria established for the category of membership for which I am applying and authorize the VSA to verify the accuracy of information provided.