AOAO Membership Application

Join AOAO

AOAO 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 #:

Contact Preference:

mailing
billing

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 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* ($350)
Associate ($200)
Military ($200)
Allied Health Professional ($175)
Disabled ($100)
Candidate (FREE)
Associate Candidate-Resident (FREE)
AOAO Active-Fellowship (FREE)

AOAO Virtual Library

The Dr. John H. Drabing Virtual Library of the AOAO Foundation serves as a members-only portal to the most used and useful journals all in one online location. More information here

Subscribe to Virtual Library?

Yes - $375
No

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:

Name on Card:

Card Address:

Card Zip Code:

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.

Expiration Date:

* 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 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.

By submission of this form I agree to the terms of payment.