Western Trauma Association (WTA) Membership Application

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Membership Application
Applicant Information
Office Address
Choose "Other" for locations outside of U.S. and Canada
1. Home Address
Choose "Other" for locations outside of U.S. and Canada
2. Education
(Institution, Degree, Year)
(Institution, Degree, Year)
(Institution, Degree, Year)
3. Board Certification
4. Curriculum Vitae *This question is required.
The picture should be recognizable, but official 'suit and tie' pictures are discouraged
5. Photo
6. Western Trauma Sponsoring Member
A sponsor letter is required with your application. You have the option to email your sponsor letter to carrie@westerntrauma.org or upload it with this application.
7. Sponsor Letter Submission *This question is required.
8. Upload Sponsor Letter *This question is required.
8. Western Trauma Association Meetings Attended
Required for membership
9. Abstracts Submitted to Western Trauma Association
10. Papers Presented at Western Trauma Association
Sign name using mouse or touch pad
Signature of