FELLOWSHIP PROGRAM DIRECTOR REFERENCE FORM FOR JUNIOR MEMBERSHIP APPLICANTS

All fields are required  

Please Enter the Sponsor’s Information:

First Name:
Middle Name:
Last Name:
Degree:
Email:
Phone: - - ext.:

Please indicate the name of the person applying for membership:

is applying for Junior membership status in the Society of NeuroInterventional Surgery and has listed you as a Neurointerventional Fellowship Program Director Reference.
Junior Members in the Society of NeuroInterventional Surgery are required to:
  • Be in training in an interventional neuroradiology, endovascular neurosurgery or interventional neurology program;
  • Have a letter of reference from their Program Director.

Neurointerventional Fellowship Program Questionnaire:

1. How long have you known the applicant?
 
2. Is the applicant a current neurointerventional fellow under your direction?
 
3. Approximately how many neurointerventional procedures are performed per year at the institution(s) where the applicant was training?
 
Do you feel that the applicant is as a Junior Member of SNIS?
Comments:
***This reference is considered confidential to the extent permitted by law.