To Join The Association For Ethics in Spine Surgery Please Fill Out the Following Membership Application Form

I, Name: *  Last Name: *  Title (MD, PhD, etc): *
agree to the following membership requirements to become a Full Member or an Affiliate Member

1. Have the majority of practice devoted to spinal surgery.

2. AFFILIATE MEMBERSHIP: Health care practitioners, including non-surgeons and non-physicians, who are interested in supporting the principles of the Association or who are interested in spine care. These may include pain management physicians, physical medicine and rehabilitation physicians, residents, physician assistants, physical and occupational therapists, and chiropractors.

3. Do not accept compensation, stock, stock options, or royalties from companies for using or implanting any device the company makes.

4. Do not own any portion of a distributorship or the like for any devices used in spinal care.

5. Believe that violations of #3 and #4 are unethical because they create an inherent conflict of interest that places financial gain over patient care.

6. FULL MEMBERS should be members in good standing in either the American Academy of Orthopaedic Surgeons, the American Association of Neurological Surgeons, the American Osteopathic Association or the Congress of Neurological Surgeons.

Please fill in which organization you are a member of

If you meet the above requirements and would like to join the Association, please fill out the following declaration:

DECLARATION: I declare under penalty of perjury that my membership information is true and correct to the best of my knowledge and belief.
As to that information, I declare under penalty of perjury that the information accurately describes as well, any related information provided to me, and that I believe it to be true.

Dated this day of 2008, in the County of , State of .