By filling out and submitting the form below, I hereby make application of membership to the Oregon Academy of Ophthalmology.

Name:
Date:
Office Information:
Business Address:
City:
State:
Zip:
Phone:
Fax:
E-Mail:
Personal Informaton:
Home Address:
City:
State:
Zip:
Phone:
E-Mail:
Spouse's Name:
Professional Informaton:
Medical School:	Year:
Residency:	Year:
Fellowship:	Year:
Subspecialty (if any):
Other Society Memberships:	OMA County Medical Society AAO
	Other
Sponsorship:
Proposed by:	(OAO Member)
Seconded by:	(OAO Member)
	A dues statement will be mailed to you upon election to the Oregon Academy of Ophthalmology. According to the OAO Bylaws, Section 2(a), "Each candidate for membership as an Active, Member-in-Training, or Non-resident member shall submit an appropriate membership application form supplied by the Academy. The form shall be completed in full, signed by two current Active or Non-resident members of the Academy as sponsors of the applicant, and returned to the Academy for review. (b) A notice of application for membership shall be submitted to the Academy members together with a call for comment by a date certain. If no objections are received, the applicant shall automatically become a member in the appropriate category."