MEMBERSHIP APPLICATION FORM Deadline July 1st Note: Do not hit "return" until ready to submit (except for the text area discussion field Noted with *).
Date:
Name of candidate:
Office address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, DC
West Virginia
Wisconsin
Wyoming
Zip:
Country:
Office Phone:
Office Fax:
E-Mail:
Place of Birth:
Date of Birth:
Citizenship:
State Medical License(s):
Premedical Education:
School:
Location:
Years
From: To:
Academic
Year:
Medical Education:
School:
Location:
Years
From: To:
Academic
Year:
Internship (postgraduate year 1):
Hospital:
Location:
Years
From: To:
Residency in Ophthalmology (postgraduate years 2-4(5)):
Institution:
Location:
Years
From: To:
Fellowship in Ophthalmology:
Institution:
Location:
Type:
Years
From: To:
Institution:
Location:
Type:
Years
From: To:
Hospital Appointments (current only):
Hospital:
Location:
Since:
Hospital:
Location:
Since:
Hospital:
Location:
Since:
Academic Appointments:
Title:
School:
Location:
Years
From: To:
Title:
School:
Location:
Years
From: To:
Title:
School:
Location:
Years
From: To:
Title:
School:
Location:
Years
From: To:
Nonacademic Appointments - AAO/Society:Committees, Editorial Boards, etc - *past 5 years:
Title:
Year: To:
Title:
Year: To:
Title:
Year: To:
Title:
Year: To:
Current Certification by the American Board of Ophthalmology:
Yes
No
Year Certified/Recertified
Other Accrediting or Certifying Body Outside USA:
Membership in medical societies:
Current Teaching Activities (medical students, residents,
fellows, peers):
Research (titles, dates,
funding sources - past 5 years)
Honor awards, named lectures, etc.:
Public service activities (projects and dates - past 5 years):
On no more than one page briefly discuss: (1) your reasons for wanting to join the AOS, (2) significant past achievements and (3) any additional details that the Committee on Membership should know about you.
Bibliography most important contributions for the last 10 years only , including articles in peer-reviewed journals, book titles, book chapters, abstracts, and video publications. Preference should be given to articles where you are the first author. Do not list materials "in press, submitted, or in preparation." Please choose one of the following three (3) methods:
1) applicant-cvs@aosonline.org
2)
3) The American Ophthalmological Society
Nominating Sponsor
Seconding Sponsor
Please re-enter your e-mail address to serve as your signature
