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FederationRwandaRรฉunionSaint BarthรฉlemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTรผrkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweร land Islands Country Cell PhonePersonal Email Medical Education:Undergraduate School(Required) Undergraduate School Degree(Required) Post Graduate School(Required) Post Graduate School Degree Medical School(Required) Medical School Degree: Residency Institution:(Required) Resident Year Started:(Required)Year Completed / Will Complete:(Required)Areas of Specialization:(Required) Fellowship Institution: Fellowship Year Started:Year Completed/To Be Completed: Areas of Specialization: Experience and Specialty:Hospital Affiliations:(Required)Teaching Program Affiliations:Society Memberships (Abbreviate):Are you board certified in your specialty?(Required) YES NO ELIGIBLE If yes, year of cerfitication:Specialty:(Required) Radiation Oncology Head and Neck Surgery Neurosurgery Ophthalmology Rhinology Pathology Maxillofacial Surgery Plastic Surgery Otology/Neurotology Radiology Other Specialty Other:(Required) References:ACTIVE APPLICANT: One (1) Active NASBS member INTERNATIONAL APPLICANT: One (1) Active NASBS member CANDIDATE APPLICANT: One (1) Active NASBS members and a letter of good standing from Program Director AFFILIATE: 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