AOAO Membership Application Join AOAOAOAO Membership Application Required fields are marked in red. First Name: Middle Initial: (if any) Last Name: Title(s): 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 #: 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: 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: / (MM / YYYY) 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 (FREE) AOAO Active-Fellowship (FREE) Payment The following payment information is required UNLESS you are applying for Candidate or Fellowship Membership Card Type: VISA MasterCard Discover American Express Card Number: Expiration Date: Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 20222023202420252026202720282029203020312032 Security Code: For VISA or MasterCard it is on the back of your card in the signature box. The 3-digit code is printed on the right-hand side of your 16-digit credit card number. For American Express the code is the 4-digit number printed on the front of your card either on the right-hand side directly above the credit card number or the left-hand side directly above the credit card number. Name on Card: Card Billing Address: Card Zip Code: * This is a secure transaction system. However, additional documentation may be required. 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 firstname.lastname@example.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. By submission of this form I agree to the terms of payment.