Society of Laparoscopic & Robotic Surgeons

Outstanding Minimally Invasive Surgery Resident Nominee:

Please provide the following information about the nominated Resident. We will use this information to create their membership with SLS:

Resident's First Name *

Resident's Middle Name/Initial:

Resident's Last Name *

Resident's Degree *
MD MD MBA MD PhD DO Other Please enter in box below

Resident's Email: *

Resident's Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Address listed is the Resident's: *
Personal/Home Address Work/Institution Address

Resident's Specialty: *
General Surgery Gynecology Urology Colon/Rectal Surgery Gynecology/Fertility Obstetrics & Gynecology Pediatric Surgery Plastic Surgery Thoracic Other Please list in box below

Date Resident is scheduled to complete residency (Month/Year - Example: 07/2025) *

Program Director / Chairman

Please provide the following information about the Chairman or Director who nominated Resident:

Director/Chairman's First Name *

Director/Chairman's MIddle Name/Initial

Director/Chairman's Last Name *

Director/Chairman's Degree *
MD MD MBA MD PhD DO Other Please enter in box below

Name of Institution *

Title/Position *

Mailing Address: *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone Number * ### - ### - ####

Fax Number ### - ### - ####

Program Director/Chairman's Email *

Banquet Date

Your Residency Program Banquet Date * MM / DD / YYYY

Name/Email Address of Person to whom we should send certificate:

Name of person to whom we should send certificate: * First Last

Email Address to send certificate: *

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Society of Laparoscopic &amp; Robotic Surgeons

Outstanding Minimally Invasive Surgery Resident Nominee:

Program Director / Chairman

Banquet Date

Name/Email Address of Person to whom we should send certificate:

Society of Laparoscopic & Robotic Surgeons