AOCOO-HNS Fellowship Application

Description: Members of the AOCOO-HNS may be granted the title of Fellow of the American Osteopathic College of Ophthalmology or the American Osteopathic College of Otolaryngology- Head and Neck Surgery.

Candidates for fellowship must meet the requirements of the Awards Committee and shall, with the approval of the Board, receive the honor of Fellow (FAOCO).

Eligibility Requirements: A candidate must demonstrate the following.

Active, continuous membership in good-standing with the AOCOO-HNS.

Certification by the American Osteopathic Board of Ophthalmology and Otolaryngology- Head and Neck Surgery.

Attendance at three (3) Annual Clinical Assembly meetings of the AOCOO-HNS following board certification. The three meetings need not be in consecutive order.

Outstanding contributions to the specialty practice, research, or to other meritorious services such as:

Educational Program Chair
Residency Program Director
Residency Faculty Member actively involved in residency training
Preceptor to medical students
Leadership positions in national, state or regional medical societies
Significant contribution to a research project
Service to the community as a physician such as mission work
Outstanding charitable support to the Foundation
Eligible fellows must be present at the Awards Ceremony (in-person or virtual) to receive the official certificate and to be formally inducted into the College as a Fellow.

What is your specialty

I hereby formally apply for Fellowship in the American Osteopathic Colleges of Ophthalmology and Otolaryngology-Head and Neck Surgery (F.A.O.C.O.) and pledge my loyalty to the ByLaws of the organization and to the rules governing such membership.

I understand that to maintain such Fellowship, I must uphold high professional and ethical standards and pay the prescribed annual dues to the organization.

Date

Signature

Type your name as you wish it to appear on your certificate

Name

First NameLast Name

AOA Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

College of Ostepathic Medicine

Year graduated

Residency Specialty Training Institution

Program Director

Year Completed

AOBOO-HNS Certification Year

Certificate Number

AOCOO-HNS Active Member since (year)

List ACA meetings attended during the past five years

List hospital staff appointment

List all activities and services to the AOCOO-HNS

List Professional Activities (i.e., teaching, membership and service to regional and national professional organizations, hospital committee work, research, etc.)

List Any Significant Achievements in the Practice of Medicine and Service to the Public and Community

Are you now, or have you at any time in the past, been involved in any action or proceeding (regardless of the outcome) involving denial, revocation, suspension, reduction, limitation, reprimand, censure, probation, non-renewal or voluntary relinquishment as follows (Please Note: Any false statements will lead to denial or revocation of Fellowship designation):

Medical License in Any State

YesNo

Other Professional Registration/License

YesNo

Academic/Faculty Appointment

YesNo

Membership on Hospital Staff

YesNo

Clinical Privileges

YesNo

Membership in a Professional Society/Fellowship/Certification

YesNo

DEA or Other Controlled Substance Registration

YesNo

Please provide two (2) certified members of the colleges endorsing this application. These references will be contacted by staff.

(1) AOCOO-HNS CERTIFIED Member Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

(2) AOCOO-HNS CERTIFIED Member Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Please upload a recent photograph/headshot

Please upload CV

E-Signature- I attest that all information contained herein on the Application is true and complete to the best of my knowledge.

All applications MUST include a complete and signed Application form, a recent photograph, and current curriculum vitae. A fee of $300 is due upon approval of Fellowship status. Accepted Fellows must attend the Annual Clinical Assembly Awards Banquet the year they get accepted as fellow to receive their fellowship status and award.