MEMBERSHIP APPLICATION FORM
Deadline July 1st
Note: Do not hit "return" until ready to submit (except for the text area discussion field Noted with *). Use "Tab" or your mouse to advance between fields, or the form will be submitted prematurely..
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 Attended:
From:
To:
Academic Degree:
Year:
Medical Education:
School:
Location:
Years Attended:
From:
To:
Academic Degree:
Year:
Internship (postgraduate year 1):
Hospital:
Location:
Years Attended:
From:
To:
Residency in Ophthalmology (postgraduate years 2-4(5)):
Institution:
Location:
Years Attended:
From:
To:
Fellowship in Ophthalmology:
Institution:
Location:
Type:
Years Served:
From:
To:
Institution:
Location:
Type:
Years Served:
From:
To:
Hospital Appointments (current only):
Hospital:
Location:
Since:
Hospital:
Location:
Since:
Hospital:
Location:
Since:
Academic Appointments:
Title:
School:
Location:
Years Served:
From:
To:
Title:
School:
Location:
Years Served:
From:
To:
Title:
School:
Location:
Years Served:
From:
To:
Title:
School:
Location:
Years Served:
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:
Yes
No
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.
(Carriage Return can be used in this field.)
Bibliography
Please use a separate sheet for the bibliography. List your 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) E-mail Attachment:
Microsoft Word format to:
applicant-cvs@aosonline.org
If e-mailing please enter the filename you will attach:
2) Fax
Attention: Stephen Moss
(415)561-8531
3) Postal Mail
The American Ophthalmological Society
P. O. Box 193940
San Francisco, California 94119
ATT: Stephen Moss
Other:
Nominating Sponsor
Seconding Sponsor
Please re-enter your e-mail address to serve as your signature