FAER Visiting Professor Program Registration
Thank you for your interest in becoming a FAER Visting Professor!

Please complete the following form to sign up to be a FAER Visiting Professor and email this form to FAER@faer.org.  FAER will contact you after you complete the registration form to finalize your enrollment.

* indicates a required field

First Name *

Last Name *

Middle Initial

Email Address *

Daytime Phone Number Type *
Office:  
Home:  
Cell / Mobile:  

Preferred Mailing Address *

		
Full Professional Title *

Academic Degrees *
	MD
	DO
	PhD
	MBA
	MPH
	Other:   

Affiliation (Department and Institution) *

Recent Visting Professorships
Please list up to three of your most recent visting professorships. Include the following information for each:

1.	Instutition Name
2.	Department Name
3.	City, State

Visting Professorship [one] *

Visting Professorship [two]

Visiting Professorship [three]

Lecture and Seminar Topics
Please use the following section to identify your topics/areas of interest for your visiting professor lectureships.

For each topic, list the title and primary objectives of the lecture, seminar or journal club. Please also select the profile category, surgical category and organ category that best correlates with the topic.

You must provide at least one topic. You may list up to three topics.

This information will be used on your visiting professor profile on FAER.org so that anesthesiology departments can view your areas of expertise.

TOPIC ONE: Title and Primary Objectives of Lecture, Seminar, Journal Club, etc. *

TOPIC ONE: Profile Category (Choose all that apply) *
	Basic Science
	Pathophysiology
	Clinical care preop
	Clinical care intraop
	Clinical care postop
	Other:  

TOPIC ONE: Surgical Category (Choose all that apply) *
	Ambulatory
	Cardiac
	ENT
	General
	GYN
	Neuro
	OB
	Opthalmology
	Pain chronic
	Pain postop
	Pediatrics
	TEE
	Thoracic

	Trauma
	Vascular
	N/A
	Other:   

TOPIC ONE: Organ Category (Choose all that apply) *
	Aorta
	Brain
	Heart
	Kidney
	Liver
	Lung
	Vasculature
	N/A
	Other:    

TOPIC TWO: Title and Primary Objectives of Lecture, Seminar, Journal Club, etc.

TOPIC TWO: Profile Category (Choose all that apply) *
		Basic science
		Pathophysiology
		Clinical care preop
		Clinical care intraop 
		Clinical care postop
		Other:  

TOPIC TWO: Surgical Category (Choose all that apply)
	Ambulatory
	Cardiac
	ENT
	General
	GYN
	Neuro
	OB
	Opthalmology
	Pain chronic
	Pain postop
	Pediatrics
	TEE
	Thoracic
	Trauma
	Vascular
	N/A
	Other:   

TOPIC TWO: Organ Category (Choose all that apply) *
	Aorta
	Brain
	Heart
	Kidney
	Liver
	Lung
	Vasculature
	N/A
	Other:    

TOPIC THREE: Title and Primary Objectives of Lecture, Seminar, Journal Club, etc. 

TOPIC THREE: Profile Category (Choose all that apply) *
	Basic science
	Pathophysiology
	Clinical care preop
	Clinical care intraop 
	Clinical care postop
	Other:  

TOPIC THREE: Surgical Category (Choose all that apply)
	Ambulatory
	Cardiac
	ENT
	General
	GYN
	Neuro
	OB
	Opthalmology
	Pain chronic
	Pain postop
	Pediatrics
	TEE
	Thoracic
	Trauma
	Vascular
	N/A
	Other:   

TOPIC THREE: Organ Category (Choose all that apply) *
	Aorta
	Brain
	Heart
	Kidney
	Liver
	Lung
	Vasculature
	N/A
	Other: