Student Osteopathic Surgical Association       
NSUCOM  SOSA APPLICATION

Name_________________________________________________________

E-mail_________________________________________________________

Address________________________________________________________

City_______________________________ State______  Zip______________

Phone_____________________  Program:   DO   DMD   PA    MBS  

Check all areas of interest:

___General Surgery                                    ___Orthopedic Surgery

___Oral Maxillofacial Surgery                   ___Plastic Surgery

___Pediatric Surgery                                  ___Otolarnygology

___Neurosurgery                                         ___Vascular Surgery

___Gynecological Surgery                         ___Urology

___Anesthesiology                                       ___Hand Surgery

___Invasive Radiology                                 Other__________________

Would you like to take part in a shadowing program with area surgeons?                 
          ___Yes  ___No

If so, when would you want to take advantage of this opportunity?

___weekends                        ___week day afternoons (late)  
            ___vacation (specify:________________________)

If so, what type of surgeon would you like for us to match

you with? _______________________________.

Please make Checks/Money Orders for:
$60.00 payable to SOSA    (M2/PA Students $35.00) 

For additional information, please feel free to email us at nebel@nova.edu