KCSO&O New Member

Kansas City Society of Ophthalmology and Otolaryngology

New Member Application
Thank you for your interest in becoming a member of the Kansas City Society of Ophthalmology and Otolaryngology!

If you have any questions, please contact the CME Provider and society manager, INMED, at cme@inmedce.com, or call us at 816-444-6400, ext 6.

Annual membership dues are $250 and allow members access to the Society's Annual Conference. If your application is approved by KCSO&O's Board of Directors, an invoice for payment will be sent to the email provided.
Personal Information
Name*

First NameLast Name
Credentials*

MDDOOther
General field*

OphthalmologyOtolaryngology
Email*
Please place email you are most likely to check.
Mobile phone number

Area CodePhone Number
Office name (if self-employed, please indicate below)*
Mailing address: *

Street Address

Street Address Line 2

CityState / 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 *

Browse Files

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Endorsement and Signature
Please provide the name of a Fellow of the KCSO&O who will endorse your application: *
I hereby make application for membership in the Kansas City Society of Ophthalmology and Otolaryngology. In so doing, I 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 my name, I am electronically signing this agreement and authorizing the form above. *

First NameLast Name
Todays Date:*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

	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

	Speciality	American Board Certifications	Date Certified
Ophthalmology
Otolaryngology

Kansas City Society of Ophthalmology and Otolaryngology