AOAO Membership Application

Join AOAO

Required fields are marked in red.

First Name:
Middle Initial: (if any)
Last Name:
Degree:
Title:
Gender: male
female
 
Note: The AOAO does not provide member phone/email information to outside vendors. Please supply your email address to expedite important AOAO communications in a more timely and cost effective method.
 
E-Mail Address:
Secondary E-Mail Address:
AOA # (required for DOs):
 
 
Please mark which address
you would like in a published
directory and the website: 		mailing
billing
neither

MAILING ADDRESS

Address Line 1:
Address Line 2: (if any)
Address Line 3: (if any)
City:
State:
ZIP Code:
Phone Number:
Cell Phone Number:
By providing your mobile number, you agree to receive text messages from AOAO regarding important member updates. Message & data rates may apply. You may reply STOP to unsubscribe at any time. Your information will be kept secure and not shared with third parties. Click HERE to view our texting policy.

Fax Number: (if any)

BILLING ADDRESS

Address Line 1:
Address Line 2: (if any)
Address Line 3: (if any)
City:
State:
ZIP Code:
Phone Number:
Fax Number: (if any)
 

Doctoral and Postdoctoral Training

EDUCATION

Osteopathic Medical School:
Location:
Graduation Date: / (MM / YYYY)
Undergraduate Education
Institution:
Location:
Begin Date: / (MM / YYYY)
End Date: / (MM / YYYY)
Advanced Degrees?
 
Residency Institution:
Location:
End Date: /
Fellowship Institution:
Specialty:
End Date: / (MM / YYYY)
Are you board eligible: yes
no
 
Are you board certified: yes
no
 
Academic Affiliations:
Hospital Staff Positions
Currently Held:
Primary Institutions and
Locations:
Specialty:
 
 
All applicants will be reviewed by AOAO, and applicants will receive prompt notice when approved.
 
Membership category: Active* ($475)
Associate ($200)
Military ($200)
Allied Health Professional ($175)
Disabled ($100)
Candidate/Resident (FREE)
AOAO Active-Fellowship (Fellowship Training) (FREE)
 

* If applying for Active membership, please provide: copy of state license and proof of board certification, if applicable. Please submit this documentation via email to membership@aoao.org, via fax to (804)282-0090, or via mail to AOAO, 2209 Dickens Rd., Richmond, VA 23230-2005.

If accepted for membership, I agree to abide by the Code of Ethics and the Constitution and Bylaws of AOAO. By Submission of this document, I authorize release of the information contained in herein and in membership files of those organizations and hospitals to which I may subsequently apply for membership, and the release to AOAO by organizations and hospitals of information relative to my previous membership in those organizations. I am a resident or a licensed physician in compliance with the state board of medical licensure and/or discipline's order.