Active Membership Application

Applications are approved yearly at the AAPOS Annual Meeting.

Candidates for membership as Active, Associate, Affiliate, International, and Orthoptist members are approved yearly at the Business Meeting of the AAPOS Annual Meeting. New member letters are sent out 1-2 weeks following the Annual Meeting.

Please note that applicants are required to provide complete and accurate professional information and are responsible for obtaining references and verifications for credentials, licenses, certifications and educational requirements.

Personal Information

First Name & Middle Initial *

Last Name *

Credential *

Email *

PLEASE NOTE: An acknowledgement of the application will be sent by email to this address. This entry must be accurate; otherwise, no acknowledgement will be received.

Primary Office Address

Office/Clinic/Institution *

Office Street Address *

Address Line 2

City *

State *

Zip Code *

Country *

Office Phone *

Office Fax

Cell / Mobile

Please include area code / country code.

Medical License Information

Do you have a valid Medical License? *

Yes No

Medical License Number *

State / Province *

Professional Affiliation

You MUST be certified by one of these organizations. Please select your professional certification. *

American Board of Ophthalmology American Osteopathic Association Royal College of Physicians and Surgeons of Canada

You must be in good standing as a fellow or member of one of the following. Please select your membership. *

Active Fellow of the American Academy of Ophthalmology Active Fellow of the American Osteopathic College Active Member of the Canadian Ophthalmological Society

Professional Information & References

College / University *

Start Date *

End Date *

College / University

Start Date

End Date

Medical or Osteopathic School *

Start Date *

End Date *

Internship *

Start Date *

End Date *

Residency *

Start Date *

End Date *

Fellowship Training Requirements. Please select your fellowship training: *

I have satisfactorily completed an Association of University Professors in Ophthalmology compliant fellowship in 2006 or later I have satisfactorily completed an AAPOS approved fellowship program (for fellowships completed after 1996 and before 2006) I have completed one year of fellowship training in pediatric ophthalmology and/or strabismus under direction of an AAPOS Member (for fellowships completed in 1996 or earlier)

Fellowship Training *

Start Date *

End Date *

Was this position under the direction of an AAPOS/AUPO approved program?

Yes No

Fellowship Director *

Fellowship Director Email Address *

AAPOS Member Reference *

AAPOS Member Reference Email Address *

Full AAPOS Member reference other than Fellowship Director

Percentage of practice related to pediatric ophthalmology and/or strabismus:

Percentage *

Signature

I understand my responsibilities as an applicant. I have reviewed my application and have provided accurate information. *

Reenter your email *

You will have the opportunity to review and edit your form entries.