Arthur Purdy Stout Society of Surgical Pathologists

Membership Application (electronic)

Eligibility: Any pathologist is eligible for membership who: 1) is certified by the American Board of Pathology, Royal College of Physicians and Surgeons of Canada in Anatomic Pathology or an equivalent foreign specialty board acceptable to the Membership Committee, 2) is five years after Board certification, 3) is actively engaged in the teaching of surgical pathology and/or an associated subspecialty of surgical pathology, and 4) demonstrates an ongoing commitment to furthering excellence in academic surgical pathology.

Nominee Name:
Telephone Number:
Fax Number:
Mailing Address:
E-mail address:
Citizen of:

Professional Information

Current Position / Title:
Medical Education:
Degree:		Date:
Anatomic Pathology Residency:		Date Completed:
Specialty Certification:		Date:

Names and e-mail address of two members of the Society who will sponsor the applicant’s nomination. Each should be from different institutions. One, if possible, should be from the nominee’s institution.
Sponsor #1
Name:		Institution:
E-mail:
Sponsor #2
Name:		Institution:
E-mail:

File Uploads

Curriculum vitae: (PDF, DOC, or DOCX only)

PDF of 3 peer-reviewed publications listing the nominee as the first or senior author: Publication #1 Publication #2 Publication #3

Please note that upon acceptance, the Treasurer will send a bill for dues, and in subsequent years, a dues statement that includes a subscription to the Journal.

By submitting this application, I hereby apply for membership in the Arthur Purdy Stout Society of Surgical Pathologists and if elected, agree to abide by the rules of the Society.

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