Specialty Credentialing Application

  • I certify that information contained in this application is true and complete. I understand that false information may be grounds for non-approval to desired specialty or for immediate revocation of distinction at any point in the future, if approved as a Fellow in a specialty. I authorize the verification of any or all informaiton listed above and the enclosed materials.

  • Use your mouse or finger to draw your signature above
  • The following must be submitted with this application:

    1. Sponsorship letters from one (1) surgeon.
    2. A personal statement.
    3. Affidavit pertaining to candidate's speciality experience.
    4. A character reference letter from a fellow CSA.
    5. Photocopy of NSAA Certificate/Re-certification reflecting current member of NSAA.
    6. $25 application fee: Money order or check
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    Max. file size: 8 MB, Max. files: 10.
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