Resident Member Application

IMPORTANT NOTE:

A resident physician enrolled in an ACGME accredited residency program in ophthalmology or in a one year preliminary program before entering an ophthalmology residency, or a graduate of an AAMC or CAMCS (CAMCE) accredited medical school or resident physician participating actively in a post-graduate research program under the direction of an Active Member or Emeritus Member, may apply to become a Resident Member. An Active Member or Emeritus Member shall verify the applicant's role in their program or research by completing a reference, once the application is submitted. An individual is eligible for the category of Resident Member for the duration of their residency training. Resident Members who qualify based on research participation alone must reapply every year.

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.

I am a resident physician enrolled in (please, select one): *

A residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME) A residency program accredited by the American Osteopathic Association (AOA) in ophthalmology A one year preliminary program before entering an ophthalmology residency A graduate of an American Association of Medical Colleges (AAMC) accredited medical school A graduate of Committee on Accreditation of Canadian Medical Schools (CAMCS (CAMCE)) accredited medical school A graduate of Commission on Osteopathic College Accreditation (COCA) accredited medical school Resident physician participating actively in a post-graduate research program under the direction of an AAPOS Active Member or Emeritus Member

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 *

Reference *

Reference Email Address *

(MUST be an ACTIVE or EMERITUS AAPOS Member)

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.