* indicates data fields that are required.
 

Member Information

Member Type:
First Name:   *
Middle Name:
Last Name:   *
Preferred Mailing Address:
Address Line 1:   *  
Address Line 2:
City   *   State   *   Zip Code   *  
 
Gender:
Date of Birth:
Email:   *
Office Phone No.:
Office Fax No.:
 

Practice Information

Practice Name:
Address Line 1:
Address Line 2:
City State Zip Code
 
Practice Phone No.:
Practice Fax No.:
Office Administrator Name:
Office Administrator Email:
 

Medical Training Information

Complete all information pertaining to your medical training, licensing, and certification
 
Medical School:
Degree(s) and Month/Year Received:
Training in Ophthalmology - Required
School/Program Name:   *
School/Program City and State:   *
Beginning Date (MM/YY):   *
Completion Date (MM/YY):   *
Subspecialized Training in Ophthalmology:   *
 

Licensing and Certification Information

Do you have a valid and unrestricted license to practice medicine?
License Number:
If No, Explain:
Certified by the American Board of Ophthalmology?
Month and Year (MM/YY):
Certified by the American Osteopathic Board of Ophthalmology?
Month and Year (MM/YY):
 

Training Verification Information

 
This is a:
School/Program Name:   *
Beginning Date (MM/YY):   *
Completion Date (MM/YY):   *
 
If you are applying for the Member-in-Training category, complete Training Verification Information section. 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.
 

Payment Information

Applicant Name:   *
(entering your name here is considered an electronic signature)
 
Amount Due: $475.00
 
Credit Card Type:
Credit Card Number:   *
Security Code:   *
Expiration Date:   *
(ex. 12/16)
 
 
 
 

What is an Ophthalmologist?

Only an Ophthalmologist – an eye physician and surgeon – is qualified to provide the full range of eye care, from treating eye diseases with medicine to performing eye surgery to prescribing eyeglasses to correct vision.