KCSO&O General Membership Renewal

KCSO&O General Membership Renewal - 2021
This form allows registration for single or group renewal of membership to the Kansas City Society of Opthalmology and Otolaryngology for the 2021 calendar year. To review full membership benefits, please visit the KCSO&O membership webpage here. Membership to the Society allows access to the 2021 conference, which will be a virtual event.

The membership fees are as follows:

$125 KCSO&O Membership per individual (2021)
$50 late fee added for KCSO&O membership renewal received after 12/31/2020.
Free for Life Time Members. Please fill out the entire form and select "Life Time Member" as a payment option.
Are you seeking Single or Group Membership?

Single Group
Were you are a member of KCSO&O in 2020?

Yes No
If you are not an active, paying member of KCSO&O and would like to apply for membership in the society, click the submit button below and you will be re-directed to our KCSO&O New Member Application form.

Group Membership
Office or Group Name *
Admin Contact Info *

First Name Last Name
Admin Email *
example@example.com
Admin Phone Number *

Area Code Phone Number
Please Note: New Members MUST fill out a separate form. This is only for renewals.

Please fill out the information for each physician seeking renewal *

First Name

Last Name

Credentials

Email (Must be Unique)

Physician

Member Information
Name *

First Name Last Name
Email *
example@example.com
Office Name *
Has any of your information changed from last year? (i.e. new office, different email, etc.) *

Yes No
If so, please tell us what has changed: *
Please list your administrator if you would like him or her to be on our email distribution list:
Admin Name:

First Name Last Name
Admin Email
example@example.com

Payment Information
Preferred Payment Information *

Credit Card (PayPal is our processor, no account is needed) Invoice or Check Life Time Member (No Payment Necessary)
Credit Card Payment
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KCSO&O 2021 Renewal $ 125.00

Quantity

Total $ 0.00
After clicking submit, a registration notification will be sent to the email provided. Please print and remit payment per instructions in the email.

Check Payments can be sent to:

INMED CE

2340 E. Meyer Blvd.

Building 1, Suite 338

Kansas City, MO 64132
Should be Empty:

KCSO&O General Membership Renewal - 2021