AAPOS Logo
AAPOS rule

American Association for Pediatric Ophthalmology and Strabismus

International Path B Membership Application
1. PERSONAL INFORMATION
01-00
First Name & Middle Initial *
01-01
Last Name *
01-02
Credential *
Example: MD, PhD, MBA, etc.
01-03
Email *
Please note: An acknowledgement of this application will be sent by email to the above address. This entry must be accurate; otherwise, no acknowledgement will be received.
01-04
2.PRIMARY OFFICE ADDRESS
02-00
Office/Clinic/Institution*
02-01
Office Street Address *
02-02
Address, line 2
02-03
City *
02-04
State *
02-05
Zip Code *
02-06
Country *
02-07
Office Phone *
(Please include area code / country code)
02-08
Office Fax
(Please include area code / country code)
02-09
Cell / Mobile
(Please include area code / country code)
02-10
3. MEDICAL LICENSE INFORMATION
03-00
Do you have a valid Medical License?*
03-01		 Yes
No
Medical License Number
03-02
Country *
03-03
4. Professional Information & References
04-00
Medical or Osteopathic School *
04-01
Start Date (month-year) *
04-02
Month: Year:
End Date (month-year)*
04-04
Month: Year:
Internship
04-06
Start Date (month-year) *
04-07
Month: Year:
End Date (month-year)*
04-09
Month: Year:
Residency *
04-11
Start Date (month-year) *
04-12
Month: Year:
End Date (month-year)*
04-14
Month: Year:
Preceptorship *
04-16
Was this position under the direction of an AAPOS Member: *
04-17		 Yes
No
Start Date (month-year)*
04-18
Month: Year:
End Date (month-year)*
04-20
Month: Year:
Preceptor's Name*
04-22
Preceptor's Email Address*
04-23
Name of a full AAPOS Member reference other than Preceptor*
04-24
E-mail address of full AAPOS Member reference other than Preceptor*
04-25
5. PROFESSIONAL EXPERIENCE
05-00
Years and months Professional Experience after last formal training.*
05-01 & 05-02
Years: Months:
6. PRACTICE COMPOSITION
06-00
Percentage of practice related to pediatric ophthalmology and/or strabismus: *
06-01
Signature
08-00
I understand my responsibilities as an applicant. I have reviewed my application and have provided accurate information. *
08-01
Please enter your email address a 2nd time. It must match the address you entered in Question 01-04*
08-02
Submit
 = You will have the opportunity to review and edit your form entries.
Copyright © 2013 American Association for Pediatric Ophthalmology and Strabismus