Category of Membership: AFFILIATE/INTERNATIONAL MEMBER
APPLICANT INFORMATION
* = REQUIRED FIELDS. INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED
MEMBERSHIP CATEGORY:
AFFILIATE/INTERNATIONAL MEMBER:
An Affiliate/International Member shall be an individual who is certified in dermatology by a non-US or non-Canadian board or its licensing equivalent OR who satisfies educational/professional requirements for certification by the American Board of Dermatology or Royal College of Physicians and Surgeons of Canada. Physicians who do not reside in the United States or Canada who are certified by either the American Board of Dermatology or the Royal College of Physicians and Surgeons of Canada may also be eligible for Affiliate/International Member status. Specialized positions in dermatology may also be eligible for this category of membership.
Membership Dues for Affiliate/International Member = $125

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  -  Do NOT publish my eMail address at all in print or on the WDS website *  
  -  Do NOT publish my contact information in print or on the WDS website *  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
  *  
Dermatology Board Eligibility Year: *  
 Dermatology Board Certification Year: *  
(use only if 'Equivalent Board' was selected) Board & Country

Dermatology Board Eligibility Year
 Dermatology Board Certification Year
(use only if 'Equivalent Board' was selected) Board & Country

Dermatology Board Eligibility Year
 Dermatology Board Certification Year
(use only if 'Equivalent Board' was selected) Board & Country

*** PLEASE NOTE:
If one of your 3 board choices as selected above is answered "Equivalent Board (Other Countries)", please describe in the text box below your dermatology equivalent board certification standards, which can include information about the examination, specific dermatology training, etc.

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
List names of two members of the Women’s Dermatologic Society from whom the Membership Committee may request letters of endorsement. One of these members should reside in the vicinity of the applicant. (Contact WDS headquarters if sponsors are needed.)

     WDS MEMBER SPONSOR #1:   *

     WDS MEMBER SPONSOR #2:   *

APPLICATION & DUES INFORMATION
INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED.
Application must be accompanied by first year’s annual dues. (Dues will be refunded if membership is not granted).

MEMBERSHIP COSTS:

  • US $125 for the annual dues
  • IF YOU DO NOT INCLUDE FIRST YEAR DUES YOUR APPLICATION WILL NOT BE ACCEPTED.

METHOD OF PAYMENT:

  • Visa
  • MasterCard
  • American Express

    Click the 'SUBMIT and PROCEED' button below and you will be taken to step 2 in the application process

PAYMENT OPTIONS:

       1 Year Membership - US $125.00
       3 Year Membership (discount) - US $350.00
       3 Year Membership (discount) - US $375.00 (US $350 dues + $25 Legacy Contribution)


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.