AOAO Membership Application Join AOAO Required fields are marked in red. First Name: Middle Initial: (if any) Last Name: Title(s): ----- DO MD PA NP/Nurse OMS I OMS II OMS III OMS IV 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: 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: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / Fellowship Institution: Specialty: End Date: / (MM / YYYY) Are you board eligible: yes no Are you board certified: yes no Academic Affiliations: Hospital Staff PositionsCurrently Held: Primary Institutions andLocations: 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.