Category of Membership: CURRENT DERMATOLOGY RESIDENT
APPLICANT INFORMATION
* = REQUIRED FIELDS. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED
MEMBERSHIP CATEGORY:
CURRENT DERMATOLOGY RESIDENT: 
PLEASE NOTE: If you have completed your dermatology residency program... PLEASE USE THIS APPLICATION

Any physician who is currently participating in a training program in dermatology which is accredited by the Accreditation Council of Graduate Medical Education (includes resident osteopathic dermatologists in an approved osteopathic program), and who is actively pursuing the educational requirements for certification by the American Board of Dermatology, or for certification in dermatology by the Royal College of Physicians and Surgeons of Canada shall be eligible to become a Current Dermatology/Post-Dermatology Residency Fellow.
Membership Dues for Current Dermatology Resident/Post-Dermatology Residency Fellow Member = Complimentary

APPLICATION DATE: *

Name: *
First * Middle Last *
Degree or Title: *
Date of Birth: *  *  *  * 
Spouse’s Full Name:

WORK MAILING ADDRESS:
Company (If Applicable):  
Address 1: *    
Address 2:  
City: *  
State: *  
Zip: *  
Country: *  
(If Other):

If you reside in a European country, you may apply for
Joint WDS-Eu/WDS membership. Click here to apply.
Phone: *  
City/Area Code *   Local Number *   Country Code *  
Fax Number:  
City/Area Code *   Local Number *   Country Code *  
eMail: *  
Citizenship: *  
Practice: *  
(If Other):
Preferred Mailing Address:
HOME MAILING ADDRESS:
Address 1: *    
Address 2:  
City: *  
State: *  
Zip: *  
Country: *  
(If Other):

If you reside in a European country, you may apply for
Joint WDS-Eu/WDS membership. Click here to apply.
Phone: *  
City/Area Code *   Local Number *   Country Code *  

PRIVACY POLICY:
  -  You may publish my contact information on the WDS website to be viewed by members only *  
  -  Do NOT publish my eMail address at all in print or on the WDS website *  
  -  Do NOT publish my contact information in print or on the WDS website *  

EDUCATION INFORMATION
Undergraduate Institution:
Institution: *  
Degree: *      Year Completed: *  
Medical or Graduate School:
Institution: *  
Degree: *      Year Completed: *  
Dermatology Residency Program:
Institution: *  
Year Completed/Proposed Completion: *   
Post-Dermatology Residency Fellowship (If Applicable):
Institution: 
Year Completed/Proposed Completion:   
Areas Of Specialization In Dermatology (If Applicable):
Institution:
Position Or Title (If Applicable):   

CERTIFICATION
American Board Of Dermatology:
Dermatology Board Eligibility Year
 Dermatology Board Certification Year

Royal College Of Physicians And Surgeons Of Canada:
Dermatology Board Eligibility Year
 Dermatology Board Certification Year

Equivalent Board (Other Countries):
          Board:      Country:           
Dermatology Board Eligibility Year
 Dermatology Board Certification Year

ADDITIONAL INFORMATION

Has your license to practice medicine in any jurisdiction ever been limited, suspended, or revoked *

Have your privileges at any hospital ever been suspended, diminished, revoked or not renewed? *

Have you ever been denied membership or renewal thereof, or been subject to disciplinary action in any local, state, or national medical society? *
Are there any charges pending resolution by a Board of Medical Examiners in any state in which you have practiced medicine? *

Have you ever been sanctioned by the Board of Medical Examiners? *

SPONSORS

     PROGRAM DIRECTOR’S NAME:   *

     PROGRAM DIRECTOR’S PHONE NUMBER:   *

Are you currently in an ACGME approved program? *
(Does not apply to applicants who reside outside of the U.S.)    

* Pre-Residency Fellows are not eligible for membership. Post-Residency Fellows may apply for Resident membership.

APPLICATION & DUES INFORMATION
INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.
The application fee and dues are waived for those applying for Resident/Fellow Status.

MEMBERSHIP COSTS:

  • US $0 for the annual dues


REFERRAL CODE:


Additional Comments:






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*Note: Use of the name of Women's Dermatologic Society
and/or the Society logo on business or in any advertisement is prohibited.
**Membership applications are reviewed and approved by the Board of Directors twice yearly.