KCSO&O New Member

Personal Information
Name *

First Name Last Name
Credentials *

MD DO
Please Select Your General Field *

Ophthalmologist Otolaryngology
Email *
Please place email you are most likely to check.
Mobile Phone Number

Area Code Phone Number
Office Name (If self-employed or retired, please indicate below) *
Preffered Mailing Address: *

Home Office
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
If you would like an Admin to be listed for communication purposes, please include his/her name, email, and phone number. If not, please write N/A. *

Educational Information
Do you have an updated CV?

Yes (you will be asked to submit it) No (you will be redirected to manually enter your education information)
Please Attach CV *

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Please Provide the Following Education Information *

	Name of Institution	Start Date	Completion Date	Degree(s)
Undergraduate Institution
Graduate Institution
Postgraduate Institution (residency or other)
Other Speciality Training
Other Speciality Training
Other Speciality Training

Code of Medical Ethics
I hereby make application for membership in the Kansas City Society of Ophthalmology and Otolaryngology. In so doing, I hereby affirm and declare that I am a legally licensed physician and, if elected, I agree to support the Charter and Bylaws of this Society and the Principles of Medical Ethics as promulgated by the American Medical Association and supported by this Society. I further affirm and declare all information is true and correct.
ELECTRONIC SIGNATURE By entering your name, you are electronically signing this agreement and authorization of the specified document above. *

First Name Last Name
Todays Date: *

Month Day Year
Date
Endorsement
Please provide the name of a Fellow of the KCSO&O who will endorse your application: *

Payment
Payment Method *

Credit Card Invoice (Check Option)
Credit Card Payment
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KCSO&O General Membership $ 175.00

KCSO&O Journal Club (2020-2021) $ 175.00

Total $ 0.00
Are you interested in attending the KCSO&O Journal Club meetings? *

Yes (an additional $175 will be added to your invoice) Not at this time I'd like more information
Total
An invoice will be emailed to you within 7 - 10 business days.
Should be Empty:

	Speciality	American Board Certifications	Date Certified
Ophthalmology
Otolaryngology

KANSAS CITY SOCIETY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY