APPLICANT INFORMATION by sofiaie

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									                                             PAAO Membership Application Form
                                                Active/Miembro Titular ($150) – MD/PhD/DO living and practicing in the Americas
                                                  Member-in-Training ($50) – In a full-time training program (Resident/Fellow)
                                          Corresponding Member ($100) – MD/PhD/DO living and practicing outside the Western
                                                                                    Hemisphere (Europe/Asia/Africa/Australia)


       PAAO                                        APPLICANT INFORMATION                                                                 BY SUBMITTING THIS APPLICATION, I AGREE THAT I HAVE
                                                                                                                                         READ AND FULLY UNDERSTOOD IT, AND I AGREE THAT EACH
                                                                                                                                         OF THE FOLLOWING STATEMENTS ARE TRUE: All information

Active Membership                                                     (Please print clearly)                                             submitted on or in support of this application is true, accurate, and
                                                                                                                                         complete. I understand and agree that all such information is subject
                                                                                                                                         to review and verification by or under the supervision of the Board of
                                                                                                                                         Directors of the Pan-American Association of Ophthalmology
An applicant for Active Member-                                                                                                          ("PAAO"). I authorize and consent to that review and verification and
ship (Miembro Titular member-           Last Name(s)                                 Suffix(es)(Sr, Jr, etc)/Degrees(MD, PhD)            all inquiries and good faith disclosures about me that may be made in
                                                                                                                                         the course of that verification process. I authorize all persons who
ship) in the PAAO shall be a physi-                                                                                                      have information about me to report such information to the PAAO. I
cian who holds a degree of Doctor       First Name(s)                                   Middle Name(s)
                                                                                                                                         hereby waive and release, indemnify, and hold harmless the PAAO
                                                                                                                                         and its Members, Directors, officers, employees, and representatives,
of Medicine, Doctor of Osteopathy                                                                                                        the endorsers of this application, and all other persons and entities, or
(or an equivalent medical degree                                                                                                         any of them, seeking, obtaining, providing, disclosing or acting upon
                                                                                                                                         any such information about me, from, against, and with respect to any
as determined by the Board of           Mailing Address                                                                                  and all claims, losses, costs, expenses, damages, liabilities, and
Directors), who holds a valid and                                                                                                        judgements of any kind arising, or alleged to have arisen, out of, with
                                                                                                                                         respect to, or in any connection with seeking, obtaining, providing,
unrestricted license to practice                                                                                                         disclosing, or acting upon any such information. I agree to comply
                                                                                                                                         with the PAAO's Code of Ethics as a condition of initial and continued
medicine in the country in which        Mailing Address (continued)
                                                                                                                                         membership in the PAAO. I understand and agree that my continued
the practice of medicine is regu-                                                                                                        status as a Member will be subject to all of the terms and conditions
                                                                                                                                         of the Bylaws of the PAAO, and that the Board of Directors of the
larly conducted, who has com-                                                                                                            PAAO may revoke my membership if this application contains or is
                                        City              State                          ZIP                              Country
pleted formal training in ophthal-                                                                                                       supported by information that omits or contains a substantial miss-
                                                                                                                                         tatement of any fact required or permitted by this application or the
mology (or its equivalent, as de-                                                                                                        related instructions to be included on or submitted with or in support
termined by the Board of Direc-         Telephone                                             FAX
                                                                                                                                         of this application.

tors), and who is a member in                                                                                                            The Pan-American Association of Ophthalmology does not discrimi-
good standing of the national so-                                                                                                        nate in membership as to race, national origin, religion, creed, gender
                                                                                                                                         or sexual preference.
ciety affiliated with the Association   Email
                                        Email is the PAAO’s primary method of communication with its members. As a member, you
in the country in which the prac-       will receive notices on upcoming meetings, events, educational programs, scholarships, and
                                        other related activities. The PAAO will protect your email address from inappropriate use.
tice of medicine is regularly con-
ducted. If the candidate has a          Languages:
                                                                                                                                         Applicant’s Signature                                                 Date
practice in more than one country,         English              Spanish             Portuguese
he or she must be a member in                                                                                                            METHOD OF PAYMENT
good standing of the national so-       Date of Birth:                   /                /             (mm/dd/yyyy)
                                                                                                                                         Payable to PAAO (include payment with application)
ciety affiliated with the Association
                                                                                                                                         Check One:         Cash           Check #
in each country in which the prac-
                                        TRAINING                                                                                            Electronic Funds Transfer
tice of medicine is conducted.                                                                                                                 Account #727257651; Account name: Pan-American Association of
                                                                                                                                               Ophthalmology; Bank name: JP Morgan Chase; Bank Address: 1301
                                                                                                                                               South Bowen Road, Arlington TX 76013; Routing/ABA 111000614;
       MEMBERSHIP                       Residency Program                                                        year completed                SWIFT code CHASUS33) INCLUDE NAME ON ALL TRANSFERS

        BENEFITS                                                                                                                            Int'l Visa    Int'l MasterCard       American Express         Discover
                                        Fellowship Program                                                       year completed          If paying with a credit card, please complete the following
 Reduced registration fees at                                                                                                           information:
PAAO congresses       and   regional
meetings.                               Subspecialty Interest(s)
                                                                                                                                         Credit Card Number (required)

 Through the Visiting Professors       CERTIFICATION                                                                                                 /
Program selected members travel                                                                                                          Expiration Date (mm/yyyy)                          Security code
to National Congresses with their       Please list the countries in which you are licensed to practice medicine. Attach a
round-trip coach airfare paid by        copy of your membership certificate from the appropriate affiliated national society.
                                                                                                                                         Name as it appears on the Credit Card
the PAOF.
 The Fellowships Committee pro-                                                                                                         Cardholder’s Signature
vides a listing of fellowships, ob-          APPLICATION ENDORSEMENT
serverships and travel awards.                                                                                                           Please note that a portion of your dues payment is considered a
                                             Application MUST be endorsed by one Active Member                                           donation to the Pan-American Ophthalmological Foundation (PAOF).
 The Research Committee re-                 (Miembro Titular) or Life Member.
views research grant applications.                                                                                                                    Do not write in this space;
                                        I,
Funding provided by the PAOF.                          (please print name of endorser in full)                                                      for accounting purposes only.
                                        certify that I am an Active Member (Miembro Titular) or Life Member of the
 The PAAO’s quarterly newsletter       PAAO; that I know the applicant
                                                                                                                                           Payment Received:
                                                                                                                                           ID #:
Vision Pan-America.
                                                                                                                                     ;     Date:
 A membership certificate.                            (please print name of applicant in full)
                                        that I am familiar with the applicant's professional competence and conduct;                       Status:
                                        that the applicant has attained a high level of professional competence and
 A membership card valid for the       conforms to the ethical standards of the PAAO; and that upon request I shall                       Source:
calendar year and issued upon           provide all necessary information to verify the truth and accuracy of this certifi-                Amount:
                                        cation.
payment of membership dues.                                                                                                                Payment type:
                                                                                                                                           Dues Year:
                                        Endorser's Signature                                                               Date
                                                        Pan-American Association of Ophthalmology
                                                      1301 S Bowen Road #365, Arlington TX 76013 USA
                                    tel: 817-275-7553     fax: 817-275-3961     email: info@paao.org                                 www.paao.org

								
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