Online PSCO Membership Form – Papanicolaou Society of Cytopathology

Select Membership Type

Membership Option *

New Membership
Renewal

Select Membership Level

Membership *

Practicing MD/PhD (DiCy e-subscription) – $140.00
Practicing MD/PhD (DiCy and Cancer Cytopath e-subscription) – $200.00
Emeritus or Retired (does not include journal e-subscription) – $25.00
Trainee/Junior MD/PhD (does not include journal e-subscription) – $0.00

Select Preferred Mailing and Email Addresses

Preferred Mailing Address *

Home
Institution/Work

Applicant Information

Name *

First

Middle

Last

Home Address *

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Preferred Email Address *

Would you like to add an alternate email address? *

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Other Email Address *

Please enter the alternate email address and indicate if it is personal or work

Untitled Document Upon approval of your application, your preferred email will be added to our ListServ

Gender *

Female
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Other

Date of Birth *

Credentials *

MD
PhD
MBBS
Other

Other Credentials *

Trainee Title *

Pathology Resident
Cytopathology Fellow
Fellow (other)

Trainee Title – Fellow Other *

Title *

Instructor
Assistant Professor
Associate Professor
Professor

Institution/Work Information

Name of Institution *

Institution/Work Address *

Address Line 1

Address Line 2

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State / Province / Region

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Institution/Work Phone *

Institution/Work Fax

Trainee Applicant Information

Name of Fellowship/Residency Program *

Fellowship/Residency Program Address *

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Trainee Residency Type – Select all that apply *

Anatomic Pathology
Clinical Pathology

Expected year of completion *

Name of Program Director *

Email of Program Director *

Applicant Education

Medical School *

Medical School Address *

Address Line 1

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Degree/Year *

Enter degree earned and year

Additional Training – Select all that apply *

Accredited Residency Program
Cytopathology Fellowship Program

Name of Accredited Residency Program *

Accredited Residency Program Address *

Address Line 1

Address Line 2

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Accredited Residency Type – Select all that apply *

Anatomic Pathology
Clinical Pathology

Accredited Residency Dates of Attendance *

Name of Cytopathology Fellowship Program *

Cytopathology Fellowship Program Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cytopathology Fellowship Dates of Attendance *

Do you have additional Cytopathology Training/Experience *

Yes
No

Additional Cytopathology Training/Experience *

Sponsor Information

I was referred by (select no more than 2) *

PSC Referral Name *

PSC Referral Institution *

PSC Referral Email *

Cytopathologist Referral Name *

Cytopathologist Referral Institution *

Cytopathologist Referral Email *

Cytopathology Program Director Referral Name *

Cytopathology Program Director Referral Institution *

Cytopathology Program Director Referral Email *

Anatomic/Clinical Pathology Program Director Referral Name *

Anatomic/Clinical Pathology Program Director Referral Institution *

Anatomic/Clinical Pathology Program Director Referral Email *

If you were not referred, how did you hear about us? *

Membership in Other Professional Organizations – Select all that apply

Membership in Other Professional Organizations

American Society of Clinical Pathologists (ASCP)
American Society of Cytopathology (ASC)
College of American Pathologists (CAP)
International Academy of Cytopathology (IAC)
US and Canadian Academy of Pathology (USCAP)
Other (please specify below)

Other Professional Organizations

Please upload your current CV and other associated documents *

Click or drag files to this area to upload. You can upload up to 4 files.

Max File Size – 512mb

Untitled Document I certify that the information contained on this application is true and complete to the best of my knowledge and belief. I agree to be bound by the Bylaws of the Society. I release from any liability all representatives of the Society for any statements made or actions taken in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and in connection with any expulsion or deletion from the rolls of membership or reapplication. I hereby release from any liability all individuals and organizations that provide information to the Society, in good faith and without malice, concerning my education and training and other qualifications for membership, and I hereby consent to the release of such information.

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Note: Receipt of payment will be sent to your Preferred Email

Total

$0.00