Spring 2025 SBAS Membership Application

2025 Individual SBAS Membership Application
SBAS membership is open to any individual who occupies a faculty position in a university department of surgery or its affiliated hospitals, a freestanding surgical residency program, an investigator or teacher in an academic department of surgery or an ACGME-approved surgery program, or an individual in a surgical specialty.

Applications for SBAS membership are considered twice per year by the Executive Council: Spring and Fall. Applications received by March 15 will be reviewed by April 25. Applications received by October 19 will be reviewed by November 30.
A non-refundable application fee is due at the time of submission. Application fees are as follows:
- Faculty/Attending application fee - $400
- Resident/Fellow application fee - $100
- Medical Student application fee - $25
Upon acceptance, your application fee will be applied to the current year's membership dues. Paying the application fee does not guarantee membership.
Personal Information
Applicant Name*

First NameMiddle NameLast NameSuffix
Degree/Credentials*
Membership Category to which you are applying:*

Faculty/AttendingResident/FellowMedical Student
Institution*
Specialty*
Professional Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Office Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
E-mail*
Non-institution e-mail address, if possible
Gender*

FemaleMaleNonbinaryPrefer not to specify
Date of Birth*

MonthDayYear

References
A total of 2 letters of reference are required for all Faculty/Attending and Resident/Fellow applicants (one from the Chairperson of your department and one from a faculty member familiar with your academic accomplishments).

Please attach your file as a PDF.
Reference 1:

Letter of reference from the Chairperson of your department
Chairperson's Name
Reference Letter 1 (.pdf)*

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Reference 2:

Letter of reference from a faculty member.
Faculty Member's Name*
Reference Letter 2 (.pdf)*

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One letter of reference is required for all medical student applicants. The letter should preferably be from a surgical faculty member at your current institution.

Please attach your file as a PDF.
Reference:
Faculty Member's Name*
Reference Letter (.pdf)*

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Additional Questions
1. Professional Experience and Expertise
- Briefly describe your current role and responsibilities in the surgical field.
- List any significant surgical, research, or medical accomplishments.
- Describe any leadership positions you have held in professional or academic settings.
- Have you been involved in any surgical societies or medical organizations? If so, please list them and describe your roles.
2. Research and Academic Contributions and Interests
- Do you have any ongoing research projects or areas of interest in medical science?
- Are you interested in participating in SBAS’ research initiatives or collaborative studies?
- Would you be open to mentoring residents or fellows on research projects?
3. Interest in Society Engagement and Activities
- Which aspects of SBAS’ activities (e.g., workshops, research collaborations, leadership development) interest you the most?
- Would you be willing to volunteer for committees or leadership roles within SBAS?
- Do you have specific ideas or initiatives that you would like to propose for the society?
4. Future Goals and Vision
- What are your professional goals over the next 5–10 years?
- How do you see your involvement in SBAS supporting your goals?
- What impact do you hope to have in the field of surgery and mentorship as part of SBAS?

Attachments and Application Fee
Please upload a current headshot (.jpg, .jpeg)*

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Please upload current CV and bibliography (.pdf)*

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Certification*

By submission of this form I certify that all information in this application is correct.
How will you be paying your application fee:*

Credit Card
Application Fee

Faculty/Attending application fee ($400)Resident/Fellow application fee ($100)Medical Student application fee ($25)
Check should be made payable to the following:

Society of Black Academic Surgeons – Tax ID# 16-1444395

Mail payments to:

Society of Black Academic Surgeons (SBAS)
633 N Saint Clair Street, Ste 2400
Chicago, IL 60611-3295

Application Fee*

Faculty/Attending Application Fee$400.00

Resident/Fellow Application Fee$100.00

Medical Student Application Fee$25.00

Enter coupon

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

If you have any questions, please contact SBAS Administration at:

Phone: 312.202.5783

Email: ngranger@facs.org

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2025 Individual SBAS Membership Application