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Specialty Fellow Membership Application

If previously a Specialty Fellow in Ophthalmology, please fill out all contact information then proceed to the payment section on page 4.

If applying as a new Specialty Fellow in Ophthalmology:

 

INFORMATION

Designation *
 
Gender *




Primary Email Type *
Preferred Address *
Preferred Phone *

MEDICAL LICENSE

Has your medical license or hospital privileges ever been revoked, suspended or restricted?
Are you aware of any current inquiry, investigation, complaint or other proceeding that could result in the revocation, suspension, or restriction of your medical license?