Scholarly Laparoscopy Search - Society of Laparoendoscopic Surgeons, Inc.

Please complete the form below and click the "Submit" button to nominate your Outstanding Resident.

PLEASE NOTE: Deadline for submission is May 7, 2010, however nominations must be received at least 30 days prior to the banquet date. To qualify as a Resident, must be in training in a U.S. accredited training program or, if outside the U.S., must be a Resident-in-Training within the first five years after medical school degree.

Please provide the following information about the nominated Resident:

Resident / First Name: *

Resident / Middle Name or Initial:

Resident / Last Name: *

Resident / Degree: *

Other Degree:

Resident / Street Address: *

Resident / City: *

Resident / State: *

Resident / Zip Code: *

Resident / Telephone Number: *

Resident / E-mail Address: *

Resident / Specialty: *

Other Specialty:

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

Program Director or Chairman / First Name: *

Program Director or Chairman / Middle Name or Initial:

Program Director or Chairman / Last Name: *

Program Director or Chairman / Degree: *

Program Director or Chairman / Name of Institution: *

Program Director or Chairman / Title-Position: *

Program Director or Chairman / Mailing Address: *

Program Director or Chairman / City: *

Program Director or Chairman / State: *

Program Director or Chairman / Zip Code: *

Program Director or Chairman / Telephone Number: *

Program Director or Chairman / Fax Number: *

Program Director or Chairman / E-mail Address: *

Your Residency Graduation Banquet Date: *

Name/Address of Person to send packet to: