LSRS Membership Application

LSRS Membership Application

Quarterly application deadlines for 2024 are: 3/1, 6/1, 9/1, and 12/1. You will need to attach your two LORs from members as part of submitting this application.
Membership Type*
Specialty*
Name*

First NameMiddle InitialLast Name
Degree(s)*
Email *
example@example.com
Organization/ Institution Name*
Current
Organization/Institution Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country*
Title*
Suggestion: Copy/Paste Signature Line
Practice Type*
Residency Information*
(List Institution and Years, ie: "University of Wisconsin, 2005-2010" or 2020-Present)
If currently in Residency, please choose which year you are in:*

PGY-1PGY-2PGY-3PGY-4PGY-5PGY-6PGY-7N/A - Not Currently in Residency
Fellowship Information *
(List Institution and Years, ie: "University of Wisconsin, 2020-2021" or 2023-Present or anticipated years)
Board Certification Year*
Board Certification Expected Date*
State Licensure *
Hospital or University affiliations not already listed:
Society Memberships:
Bibliography of publications pertaining to the lumbar spine:
Bibiography of publications pertaining to the lumbar spine:
Current Research in lumbar spine:
Current Research in lumbar spine:
Attendance at a meeting of the Lumbar Spine Research Society?*

NoYes
Two letters of recommendation are required for this application to be processed. Letters must be from current Lumbar Spine Research Society members. Attach both letters below.

LSRS Membership Directory: https://www.lsrs.org/membership-directory

List the names of both references here:
LSRS Member Name*
First and Last
LSRS Member Name*
First and Last
LOR 1*

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LOR 2*

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Upload CV*

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Upload Headshot*

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Should be Empty: