ASSOCIATE MEMBERSHIP APPLICATION



NAME: ________________________________________________________________________________________________

(Last) (First) (Middle)

MAIN PRACTICE ADDRESS: ________________________________________________________________________________

OTHER PRACTICE LOCATIONS (NAME OF CITY[IES] ONLY): _______________________________________________________

_______________________________________________________________________________________________________

HOME ADDRESS: _________________________________________________________________________________________

LEGISLATIVE DISTRICT: _______

E-MAIL: __________________________________ WEBSITE________________________________________________________

TELEPHONE: (OFFICE) _____________________________ (HOME) ______________________________________________

FAX: (OFFICE) __________________________________ (HOME) ______________________________________________

PREFER MAIL SENT TO HOME______ OFFICE_____

______PLEASE BE SURE WE HAVE A FAX # or EMAIL ADDRESS FOR YOU AS BLAST FAXING IS OUR WAY TO COMMUNICATE WITH YOU

IMMEDIACY IS IMPORTANT. THANK YOU_______________

MEDICAL LICENSE #: ______________ STATE:______ DATE: __________________

Primary SPECIALTY: _____________________ BOARD CERTIF.? Y or N DATE: _____________

Other Interests or Specialties (such as glaucoma, Lasik, etc.)

INTEREST OR SPECIALTY: ___________________________________________________

INTEREST OR SPECIALTY: ____________________________________________________

INTEREST OR SPECIALTY: ____________________________________________________

MEDICAL SCHOOL: ___________________________________________________________________________

DEGREE: _________ YEAR OF GRADUATION: ____________

INTERNSHIP: _____________________________________ DATES: _______ to _______

RESIDENCY: _____________________________________ DATES: _______ to _______

_____________________________________ DATES: _______ to _______

FELLOWSHIP(S): __________________________________ DATES: _______ to _______

__________________________________ DATES: _______ to _______

_____________________________________________________________________________________________

Memberships held in other medical associations:

AMA ArMA

OTHER _________________________________________________________________________________________

_______________________________________________________________________________________________

Continued on reverse side>



Application continued



CURRENT PRACTICE (Practice name, hospital, clinic, etc. and dates):

__________________________________________________________________________________________________________________



Please list any current business partners and/or associates:

1. _________________________________________________

(Typed Name)

2. _________________________________________________

(Typed Name)

3. __________________________________________________

(Typed Name)

4. __________________________________________________

(Typed Name)

Name and COMPLETE address of two references supporting your application.

1. ____________________________________

(Typed Name)

_______________________________________________________________________

(Address)

2. ____________________________________

(Typed Name)

_______________________________________________________________________ 

(Address)





APPLICANT'S SIGNATURE: ________________________________ DATE: _____________

PLEASE COMPLETE AND RETURN TO: ARIZONA OPHTHALMOLOGICAL SOCIETY 

810 West Bethany Home Road, Phoenix, AZ 85013

(602) 246-8901 (602) 242-2515 fax or

email to: patriceh@azmedassn.org

--------------------------------------------------------------------------------

FOR OFFICE USE ONLY

Date Approved by AOS: ________________________