AASM Fellow Membership Application

Name: / Click here to enter text. / Member Number:Click here to enter text.
Present company name or institution: / Click here to enter text.
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City/State: / Click here to enter text. / Phone:Click here to enter text.
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REQUIREMENT 1: Board Certification
You must be certified in sleep medicine by an American Board of Medical Specialties (ABMS) member board or an American Osteopathic Association (AOA) specialty certifying board OR certified in Behavioral Sleep Medicine by the ABSM.
Which board certified you in sleep medicine? (Check one)
ABMS Member boards
☐ABIM / ☐ABOto / ☐ABP (Pediatrics)
☐ABPN / ☐ABA (Anesthesiology) / ☐ABFM
AOA Specialty Certifying Board
☐Family Physicians / ☐Neurology and Psychiatry / ☐Internal Medicine / ☐Ophthalmology and Otolaryngology
☐American Board of Sleep Medicine (in behavioral sleep medicine)
Is there a pending or final disciplinary action against you by any facility or State Licensure Board?
☐Yes ☐No
If Yes, please explain Click here to enter text.
REQUIREMENT 2: Membership Tenure
Hold membership as regular member for the last 5 consecutive years
What year did you join the AASM? Click here to enter text.
REQUIREMENT 3: Special Contributions
Demonstrate special contributions to scientific literature or significant advancements in the field of sleep medicine in at least two of the following areas: Research, Service, or Education.
In two paragraphs or more state contributions for which you should be recognized. Be as detailed as possible.
3A. RESEARCH
Explain in detail your contributions to scientific literature or significant advancements in the field of sleep medicine. This may include research papers, journal articles, patents, books, peer reviewed papers, etc.
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3B. SERVICE
Explain in detail your participation in the practice of sleep medicine with proven leadership within the community relating to the advancement of sleep medicine. This may include a list of activities within the AASM or leadership at a local or regional level.
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3C. EDUCATION
Explain in detail your dedication to the advancement of the sleep medicine through teaching. This may include the development of courses, training of medical students, residents and fellows, or provision of continuing medical educations in sleep medicines.
Note: The activities you list must not be a part of your current day-to-day work.
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Required Attachments:

☐Documentation of current certification by ABMS member board, AOA specialty certifying board, or ABSM (certified in Behavioral Sleep Medicine)

☐Curriculum Vitae

☐Letter of recommendation from someone board certified in sleep medicine by the ABSM, an ABMS member board, or AOA specialty certifying board describing the nominee’s achievements in at least two of the three above- noted areas

☐Letter of support from an independent medical professional outside the group or department of the nominee

To be considered for fellow membership, please complete this form and submit it, along with the required attachments to .
WORKSHEET

You may use this worksheet as a starting point to document some of the qualifying activities that may fulfill the fellow application requirements.

RESEARCH CONTRIBUTIONS
List of relevant papers, books, posters, etc.that have been published
Title of Paper/Book / Click here to enter text.
Author/Co-authors: / Click here to enter text.
Where published or presented: / Click here to enter text.
Date published or presented: / Click here to enter text.
Title of Paper/Book / Click here to enter text.
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Where published or presented: / Click here to enter text.
Date published or presented: / Click here to enter text.
Title of Paper/Book / Click here to enter text.
Author/Co-authors: / Click here to enter text.
Where published or presented: / Click here to enter text.
Date published or presented: / Click here to enter text.
SERVICE HISTORY
Please list activities that you have participated in within the AASM or local/regional community.
Year(s) / Name of Company, Institution, or Activity / Description
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EDUCATION HISTORY
Course Developments
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Training(Continuing education, mentorship and other training you’ve provided)
Description / Location / Year(s)
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