Step 1 of 8 - Introduction 0% If you are applying for ASMBS Membership in conjunction with Registration for any ASMBS educational event, please note the following: Upon submission of a completed application, the application is sent to the ASMBS Membership Committee for review. It can take approximately 6-8 weeks for approval. Pending members are eligible for the reduced member rate for all educational meeting and symposiums, however all applications MUST be complete, including payment, at least 30 days prior to an event in order for the discount to apply. If your application is not complete, you will not receive a refund reflecting member pricing for any ASMBS Conference.Application Instructions Please complete all entries. Missing or incomplete entries will delay application approval. In addition to the completed membership application form, the following items must be submitted: Recommendation Form* completed by a Regular, Senior, or Associate** member in good standing of the ASMBS. It is the responsibility of the applicant to upload the form at the time of completing this application. A current Curriculum Vitae (or resume) which includes education and past work experience. Regular Associate, Associate, and Affiliate Member types: a copy of your state license, registration or certification. Payment must be received before an application is reviewed. Please allow 4-6 weeks from submission of complete and paid application for review. * For those applicants who need assistance obtaining a Recommendation Form, please contact ih-membership@asmbs.org **International applicants should substitute the Member Recommendation Form from an International Member. The American Society for Metabolic and Bariatric Surgery prohibits discrimination against any member or any applicant for membership because of race, color, gender, national or ethnic origin, age, religion, disability, sex, or any other characteristic protected under applicable federal or state law.ConsentYour information and privacy is our top priority. By applying to become an ASMBS member, you agree to the terms outlined in the ASMBS Privacy Policy. ASMBS will never sell or provide your information to anyone or any business without your consent. After membership approval, ASMBS will only share your information to the entities outlined in the privacy policy to fulfill your membership benefits. You may opt out of these benefits and may request to have your information removed from ASMBS at anytime.You can read the ASMBS Privacy Policy and if you have any questions or concerns please contact the office.Provide your consent(Required) I agree Referring Member (if any)If an ASMBS member referred you to become an ASMBS Member, enter the name of the referring member here. If no member referred you, leave this blank. Individuals Employed by a Commercial Entity(Required)A full copy of the policy is available here. ASMBS is a professional healthcare society and its membership is derived from healthcare professionals. For the purposes of this policy, employment by industry exists when greater than 50% of an individual’s compensation and benefits are derived from a commercial entity. Herein, industry is broadly defined as any entity producing, marketing, re-selling, or distributing health care goods or services which are consumed by, or used on, patients. Yes No Not Sure Category of Membership(Required)Learn more about membership types here. Regular Associate Associate International Associate Affiliate International Affiliate Student Regular Associate MemberRate: $125Health Care Professionals working in the field of bariatric surgery (i.e., nurse, psychologist, dietitian, physician assistant, exercise physiologist, researcher). Requires a Recommendation From a Regular (surgeon) Member.Associate MemberRate: $125Integrated health care professionals, who have demonstrated clinical interest in the treatment and commitment to the long-term care of persons with obesity who do not otherwise qualify for IH Regular Associate Membership.International Associate MemberRate: $95Health Care Professionals working in the field of bariatric surgery outside of the United States. Requires a Recommendation From an International (surgeon) Member.Affiliate Associate MemberRate: $100Persons actively employed in a bariatric surgical practice or hospital based bariatric program who do not otherwise meet the requirements for Associate membership. Requires a Recommendation From a Regular (surgeon) Member.International Affiliate MemberRate: $70Persons actively employed in a bariatric surgical practice or hospital based bariatric program outside of the United States, who do not otherwise meet the requirements for Associate membership. Requires a Recommendation From an International (surgeon) Member.Student MemberRate: $35Full-time Students in a relevant Integrated Health Discipline. Documentation of Full time enrollment in the course of study must be included. Requires a Recommendation From a Regular (surgeon) member.Name(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. 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White Hispanic or Latino or Spanish Origin of any race - Mexican, Mexican Am., Chicano - Puerto Rican - Cuban - Other Caribbean - Central American - South American - Spaniard Black or African American American Indian or Alaskan Native Asian - Chinese - Filipino - Asian Indian - Vietnamese - Korean - Japanese - Other Asian Native Hawaiian or other Pacific Islander Some Other Race Prefer not to answer Citizenship(Required)Select...United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Contact InformationPrimary Email Type(Required) Business Personal Primary Email OptionsPublic Directory refers to the address used in Find a Surgeon. Check all that apply. Public Directory Private Member Directory Primary Email(Required) Share Primary Email with Corporate Council? Opt-In to Sharing with Corporate Council (Primary Email) Additional Email Type Business Personal Additional Email OptionsPublic Directory refers to the address used in Find a Surgeon. Check all that apply. Public Directory Private Member Directory Additional Email Share Additional Email with Corporate Council? Opt-In to Sharing with Corporate Council (Additional Email) Mailing Address Type(Required) Business Personal Mailing Address OptionsPublic Directory refers to the address used in Find a Surgeon. Check all that apply. Public Directory Private Member Directory Journals/Publications Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Additional Address Type Business Personal Additional Address OptionsPublic Directory refers to the address used in Find a Surgeon. Check all that apply. Public Directory Private Member Directory Journals/Publications Additional Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone Type(Required) Business Personal - Home Personal - Mobile Primary Phone OptionsPublic Directory refers to the address used in Find a Surgeon. Check all that apply. Public Directory Private Member Directory Primary Phone Number(Required)Additional Phone Type Business Personal - Home Personal - Mobile Additional Phone OptionsPublic Directory refers to the address used in Find a Surgeon. Check all that apply. Public Directory Private Member Directory Additional Phone Number Professional InformationLicense or Registration Number(Required) Company/Organization/Institution(Required) Website AddressFor the public and member directories. Primary Practice Setting(Required)Select one. Academic Government Hospital Military Private Practice Other Primary Disciplines(Required)Select all that apply. Advanced Practice Provider Behavioral Health Exercise Nursing Nutrition Office Staff/Scheduler/Insurance Coordinator Pharmacist Other Practice Roles(Required)Select all that apply. Administration (Non-Licensed) Bariatric Coordinator Bariatric Program Director Chief Nursing Officer Clinical Nurse Specialist Clinical Reviewer CRNA Dietitian Exercise Physiologist Licensed Clinical Social Worker (PhD, DSW, LCSW, LISW) Nurse Nurse Practitioner Physical Therapist Physician Assistant Psychiatrist (MD, DO) Psychologist (PhD, PsyD) Research Other Organizational MembershipsSelect all that apply. AADE AANP AAPA ACSM ANA AND: WM DPG ASN OMA NACNS TOS Professional DocumentationAttach CV(Required)Accepted file types: pdf, docx, Max. file size: 15 MB.Attach Recommendation Form(Required)Accepted file types: pdf, docx, png, jpg, Max. file size: 15 MB.Attach State License, Registration or Certification(Required)Accepted file types: pdf, docx, png, jpg, Max. file size: 15 MB.Other CertificationOptional. Provide details of any other professional certifications.Are you employed by the US Military/VA/DOD?(Required)Active military and those who are employed with the VA/DOD will receive a discounted rate of membership. $160.00 for Membership with the Print and Online Versions of SOARD and $60 for Membership with only the Online version of SOARD. Active military, please upload a copy of your Military ID to qualify for the discount. Not US Military/VA/DOD US Military VA/DOD Attach US Military ID(Required)Accepted file types: pdf, docx, png, jpg, Max. file size: 15 MB. SOARD (Surgery for Obesity and Related Diseases) Journal PreferencesSOARD (Surgery for Obesity and Related Diseases) Journal PreferencesIH Membership does NOT include SOARD. Add by selecting options below. No SOARD Subscription Online Access ($30.00) Print and Online Access ($100.00) Other Membership OptionsState ChaptersSelecting a state chapter below will include your state chapter membership in your ASMBS dues. Please note all states have a state chapter, however some chapters may not be eligible for payment through ASMBS. If you have any questions about state chapter membership, contact ASMBS or a representative from your state chapter. Alabama (50.00) Arizona (25.00) California/Nevada (50.00) Carolinas (25.00) Colorado (50.00) Connecticut (50.00) Dakota Yellowstone (25.00) Delaware (50.00) Florida/Puerto Rico/Caribbean (50.00) Georgia (35.00) Illinois (25.00) Indiana (25.00) Iowa (25.00) Kansas (50.00) Louisiana (25.00) Maryland (50.00) Michigan (50.00) Minnesota (25.00) Mississippi (25.00) Missouri (50.00) Nebraska (50.00) New York (50.00) Ohio/Kentucky (25.00) Oklahoma/Arkansas (25.00) Oregon (50.00) Pennsylvania (50.00) Tennessee (50.00) Texas (25.00) Virginias (25.00) Washington (25.00) Wisconsin (25.00) TREO Foundation DonationInvest in the future of obesity research and education by donating to the TREO Foundation. The TREO Foundation is a 501(c)(3) charitable organization, and as such, contributions are deductible for federal income tax purposes (to the extent provided by law). $25 $100 - Friend $500 - Donor $1,000 - Supporter No Donation Authorization and SignatureI authorize the ASMBS to obtain information from societies, hospital staff, members and other sources regarding this application and my qualifications for membership which will be kept confidential by the ASMBS. To the best of my knowledge, I state the information on this application to be accurate.(Required) I agree to authorize Electronic Signature(Required)Signature Date MM slash DD slash YYYY Application Total Payment DetailsBilling Address(Required) Same as Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country An itemized list will be provided on the confirmation page and sent to the primary email address.Credit Card(Required)Card Details Cardholder Name