Join AOAO

AOAO Student Membership Application

Required fields are marked in red.

First Name:
Middle Initial: (if any)
Last Name:
Title(s):
Birthdate:
Day: Month: Year:
 
Gender:
male
female
 
Note: The AOAO does not provide member phone/email information to outside vendors. Please supply your email address to expedite important AOAO communications in a more timely and cost effective method.
 
E-Mail Address:
Secondary E-Mail Address:
Contact Preference:
mailing
billing
 
Please mark which address
you would like in a published
directory and the website:
mailing
billing
neither

Medical School Address

Address Line 1:
Address Line 2: (if any)
Address Line 3: (if any)
City:
State:
ZIP Code:
Phone Number:
Fax Number: (if any)

Billing Address

Address Line 1:
Address Line 2: (if any)
Address Line 3: (if any)
City:
State:
ZIP Code:
Phone Number:
Fax Number: (if any)

Education

 
Medical School
Institution:
Location:
Begin Date:
/ (MM / YYYY)
End Date:
/ (MM / YYYY)
 
 
Academic Affiliations:
Primary Institutions and
Locations:
 
All applicants will be reviewed by AOAO, and applicants will receive prompt notice when approved.
 
Membership category:
Student ($20)
Select your chapter from the list:
Other Chapter
(if not listed above)
 

Payment

The following payment information is required UNLESS you are applying for Candidate Membership AND NOT applying for Case Log System access.
 
Card Type:
VISA
MasterCard
Discover
American Express
Card Number:
Name on Card:
Card Address:
Card Zip Code:
Security Code:

For VISA or MasterCard it is on the back of your card in the signature box. The 3-digit code is printed on the right-hand side of your 16-digit credit card number.
For American Express the code is the 4-digit number printed on the front of your card either on the right-hand side directly above the credit card number or the left-hand side directly above the credit card number.
Expiration Date:
/

* This is a secure transaction system. However, additional documentation may be required. If applying for Active membership, please provide: copy of state license and proof of board certification, if applicable. Please submit this documentation via email to membership@aoao.org, via fax to (804)282-0090, or via mail to AOAO, 2209 Dickens Rd., Richmond, VA 23230-2005.

If accepted for membership, I agree to abide by the Code of Ethics and the Constitution and Bylaws of AOAO. By Submission of this document, I authorize release of the information contained in herein and in membership files of those organizations and hospitals to which I may subsequently apply for membership, and the release to AOAO by organizations and hospitals of information relative to my previous membership in those organizations. I am a resident or a licensed physician in compliance with the state board of medical licensure and/or discipline's order.

By submission of this form I agree to the terms of payment.