VOS Membership Application

CONTACT INFORMATION
Required fields denoted by *
Required fields for students denoted by
Name*: 
Title*: 
Mailing Address*: 
Billing Address*: 
Home Phone*: 
Work Phone*:  Ext.
Fax: 
Email*: 
Date of Birth:  / / (mm/dd/yy)

 

EDUCATION
   
Medical School: 
Date of Graduation:  / /
Program Director’s email: 
   

 

PRIMARY EMPLOYMENT
   
Please choose one or more of the following specialties*:
Hand Elbow Shoulder Spine Hip Knee Foot and Ankle Pediatric Sports Trauma
 
Practice Setting: 
Hospital Privileges: 
 
Has license to practice medicine ever been suspended or revoked?
  Yes No
If “yes”, explain: 
 
Certification by American Board of Orthopaedic Surgeons*:
  Yes No Year
 
Board Eligible*:  Yes No
If “yes”, when will you take the examination? (year)
  Part I Part II

 

MEMBERSHIP CATEGORIES & ELIGIBILITY REQUIREMENT
Active An Active member in the Virginia Orthopaedic Society shall be certified by the American Board of Orthopaedic Surgeons and shall reside or maintain an office and practice orthopaedic surgery in Virginia. Active members have all rights and privileges in the VOS and may be elected to serve as officers or directors of the Society. $300
Associate (A) An Associate (A) member shall be .Board Eligible. in orthopaedic surgery. An Associate (A) Member shall have the right to vote and hold office in the Society. $300
Associate (B) An Associate (B) member may be an individual who is in the US Armed Forces and is engaged in the practice of orthopaedic surgery within any of the military medical installations in Virginia. An Associate (B) Member shall have the right to vote and hold office in the Society. $225
Associate (C) An Associate (C) Member shall be a physician, non-orthopaedic surgeon with an interest in musculo-skeletal care. An Associate (C) member will have no vote and will not hold office in the Society. $175
Associate (D) An Associate (D) member shall be a Physician Assistant or licensed Nurse Practitioner with an interest in orthopaedic surgery. An Associate (D) member must have an established relationship with and be sponsored by a current VOS active member. An Associate (D) member will have no vote and will not hold office in the Society.
Sponsor Name*: 

Sponsor Email*: 
$175
Associate (E) As Associate (E) member shall be an orthopaedic practice administrator or manager. An Associate (E) member must have an established relationship with and be sponsored by a current VOS active member. An Associate (E) member will have no vote and will not hold office in the Society.
Dues are free for group bill practice administrators who have all practicing orthopaedic surgeons as members of the society.
Sponsor Name*: 

Sponsor Email*: 
$100
Associate Resident Currently enrolled in an approved residency program in orthopaedic surgery at an accredited medical school in Virginia. Associate Resident members pay no annual dues. $10
Associate Fellow Currently enrolled in an approved fellowship program in orthopaedic surgery at an accredited medical school in Virginia. Associate Fellow members pay no annual dues. $10
Associate Medical Student Currently enrolled in an accredited medical school in Virginia. Free

 

PAYMENT INFORMATION
Card Type*:  Discover MasterCard Visa
     
Name printed on card*: 
Card Number*: 
Security Code*: 
Expiration Date*:  /
Card Address*: 
Card Zip Code*: 
   
Electronic Signature*: 
I certify that I meet the above criteria established for the category of membership for which I am applying and authorize the VOS to verify the accuracy of information provided.