ASPN MIS Certification Application
Application Deadline: May 31, 2026
Name
*
First Name
Last Name
Current Postion: [Interventional Pain, Spine Surgeon, Inverventional Radiology]
*
Institution/Organization: [Current place of practice/training]
*
City, Country
*
Street Address
Street Address Line 2
City
Country
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
1. Educational Background
Undergraduate: [Institution, Year, Location]
Medical School: [Institution, Year]
Residency: [Institution, Specialty, Dates]
Fellowship: [If applicable - Institution, Focus, Dates]
Year Fellowship was Completed
Supplemental MIS Training: [Workshops, cadaver courses, observership]
2. Clinical Experience
Years in Practice or Training: [Number of years]
Surgical Experience in MIS: [Procedure types, volume, supervision status]
MIS Techniques Familiar with: [tubular, endoscopic, percutaneous, fixation, etc.]
Types of Procedure
Seeking Certification in These Procedures (check up to 3 procedures)
Minimally Invasive Sacroiliac Surgical Procedures
Percutaneous Interlaminar Lumbar Decompression
Basivertebral Nerve Ablation
Interspinous Decompression and Fixation
Minimally Invasive Facet Surgical Techniques
Advanced Spinal Cord Stimulation
Peripheral Nerve Stimulation
Dorsal Root Ganglion
Endoscopic Surgery
Kyphoplasty
3. Teaching and Collaborative Experience
Teaching Role (if any): [Residents, students, lab sessions]
Participation in Team-Based Learning: [Multidisciplinary collaboration]
Conference Involvement: (Poster presentations, session moderation]
4. Publications and Research
Research Focus: [MIS-related topics or spine surgery]
Publications/Abstracts: [Cite key works or ongoing projects]
Research Aspirations: [How certification will support scholarly goals]
5. Additional Information
Describe Reason for Applying as a Candidate
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Category Desired: (Choose one) Fee not charged until acceptance.
MIS Certification: Written and Practical exam. One procedure certification: $2,000.00.
MIS Certification: Written and Practical exam. Two procedure certificates: $2,750.00
MIS Certification: Written and Practical exam. Three procedure certificates: $3,500.00
Fundamentals of MIS (Certificate of Participation): Written exam/didactic: $1,000.00
Submit
Should be Empty: