Speciality Credentialing Application - NSAA | National Surgical Assistant Association

Name*

First Middle Last

Address*

Street Address City State ZIP Code

Phone*

Email*

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NSAA Fellow Speciality Desired*

Ortho
Plastics
Gyn
Robotics

I certify that information contained in this application is true and complete. I understand that false information may be grounds for non-approval to desired specialty or for immediate revocation of distinction at any point in the future, if approved as a Fellow in a specialty. I authorize the verification of any or all informaiton listed above and the enclosed materials.

Signature*

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The following must be submitted with this application:

1. Sponsorship letters from one (1) surgeon.
2. A personal statement.
3. Affidavit pertaining to candidate's speciality experience.
4. A character reference letter from a fellow CSA.
5. Photocopy of NSAA Certificate/Re-certification reflecting current member of NSAA.
6. $25 application fee: Money order or check

File

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Max. file size: 256 MB, Max. files: 10.

Application Fee*

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Card Number Expiration Date Security Code Cardholder Name

Specialty Credentialing Application

The following must be submitted with this application: