PAO Membership Application

PAO Membership Application

1. Member Type

Active Member @ $475 Associate Member @ $237.50 Part-time Member @ $237.50 Military Member @ $175 Out-of-State Member @ $175 Member in Training @ $0
2. Personal Data

Please type your name exactly as you would like it to appear in the Academy's records and files.
Last name
First name Middle initial
Preferred mailing address for all correspondence is: Home Business
Street Address
Apt. or Suite Number
City State Zip code
Country
Office phone Office fax
E-mail address
Gender: Male Female
Date of birth
3. Practice Data
Practice Name
If different from preferred.
Practice Street Address
City State Zip code
Practice phone Practice fax
Office Administrator Name
Office Administrator Email
4. Medical Training
Complete all information pertaining to your medical training, licensing, and certification.
Medical school
Degree(s) and month/year received
Formal training in ophthalmology - required
Name of school or program
City & state of school/program
Beginning date (month/year)
Completion date or expected date (month/year)
Subspecialized training in ophthalmology
5. Licensing & Certification

Do you have a valid and unrestricted license to practice medicine? Yes No
If no, explain
Certified by the American Board of Ophthalmology? Yes ; month/year No
Certified by the American Osteopathic Board of Ophthalmology? Yes ; month/year No
6. Training Verification

Applicants applying for Member-in-Training must complete this section.
This is a: Residency Program (or formal training in ophthalmology) Fellowship Program
Please enter the name of the school or program
Beginning date (month/year) Completion date (or expected completion date) (month/year)
If you are applying for the Member-in-Training category, complete Section 6. Verification of the training program must be forwarded to our office. Forward a copy of your official letter of acceptance (begin and end dates must be included in the letter) to: PAO, 777 East Park Drive, Harrisburg, PA 17111. We will hold your membership application request until we receive the necessary documentation.
7. Payment

Name of applicant (entering your name here is considered an electronic signature)
Please check your method of payment: Visa Mastercard AMEX Discover Total payment $ Credit card number Expiration date		This is a secure site for your credit card information. Thank you for joining the PAO!

Pennsylvania Academy of Ophthalmology, 777 East Park Drive, PO Box 8820, Harrisburg, PA 17105-8820 Phone: (717) 558-7750 ext. 1518 Fax: (717) 558-7841 pao@pamedsoc.org