PAAO Membership Application

APPLICANT INFORMATION (please print clearly)

Last Name(s)Suffix(es)( MD, Sr., Jr., etc.)

First Name(s)Middle Name(s)

Mailing Address

Mailing Address

CityStateZIPCountry

TelephoneFAX

Email

Languages: English Spanish Portuguese

Date of Birth: / /

MonthDayYear

I would like to receive eVision, PAAO’s monthly electronic newsletter

I would like to receive information on educational opportunities: scholarships, meetings

I would like to receive Vision Pan-America: The Pan-American Journal of Ophthalmology

TRAINING

Ophthalmology Residency Program(Projected) Completion Date

Fellowship Program(Projected) Completion Date

Subspecialty Interest

CERTIFICATION

Please list the countries in which you are licensed to practice medicine.

Countries in which you are licensed to practice medicine

I understand and agree that my continued status as a PAAO Member will be subject to all of the terms and conditions of the Bylaws of the PAAO, and that the Board of Directors of the PAAO may revoke my membership if this application contains or is supported by information that omits or contains a substantial misstatement of any fact required or permitted by this application or the related instructions to be included on or submitted with or in support of this application.

Applicant’s SignatureDate


MEMBERSHIP DUES

Dues are based on a calendar year: from January 1 through December 31.

$200 – Active Member (ophthalmologist)

$75 – Affiliate Member (researcher, non-ophthalmologist)

$0 – Member-in-Training for the first year (With Program Letter from Department Chair or Program Director); $25 for the second year and $50 for the third-fifth year of membership (under 35 years old; maximum five years as Member-in-Training)*

*I understand that when my training ends, I will notify the Administrative Office and I will transfer my membership to Active Member status.

 Additional gift to the PAOF

METHOD OF PAYMENT

Payable to PAAO (include payment with application)

Check one: Cash Check #

Int'l VisaInt'l MasterCardAmerican Express Discover

If paying with a credit card, please complete the following information:

Credit Card Number

Name as it appears on the Credit Card

Expiration Date (mm/yy)Security Code

Cardholder’s SignatureDate

REMIT TO:

Pan-American Association of Ophthalmology (PAAO)

1301 South Bowen Road, Ste. 450

Arlington, TX 76013-2286 USA

Tel.: +(817) 275-7553 FAX: +(817) 275-3961

Questions? Contact:

Do not write in this space;For accounting purposes only.

Payment Received: ID #

Date: Status:

Source: Payment Entered

Amount: Date:

Payment type: By:

Dues Year: Payment #:

MEMBERSHIP BENEFITS

Membership in the Pan-American Association of Ophthalmology offers you the opportunity to reach across countries and cultures to build life-long relationships with other colleagues who are deeply committed to sharing new ways to standardize and advance ophthalmic knowledge and skills for the improvement of patient care.

As an active member, the following benefits are available to you:

  • Multilingual state-of-the-art Portal (website) offering cutting-edge ophthalmic education through virtual meetings, blogs and webinar presentations that will be accessible 24 hours a day seven days a week
  • Reduced registration fees at PAAO congresses and regional meetings
  • February 20-21, 2014 … 22ndPan-American Regional Course in Panama City, Panama
  • May 5, 2014 … Pan-American Research Day (PARD) in Orlando, Florida
  • May 29-31, 2014 … 23rdPan-American Regional Course in Punta del Este, Uruguay
  • October 22, 2014 … 28th Best of the academy in Spanish in Chicago, Illinois
  • August 4-8, 2015 … 31stPan-American Congress of Ophthalmology in Bogotá, Colombia
  • Prizes and Awards
  • Lions/PAAO Award for the Prevention of Blindness
  • Paul Kayser/RRF Global Award offering an award to visual scientists in the forefront of innovative clinical and basic science in ophthalmology
  • Troutman-Véronneau Prize
  • Fellowships, scholarships, travel awards and specialty training opportunities
  • Visiting Professors Program affords members an opportunity to travel to National Congresses
  • Scholarships to the ARVO meeting available for young and promising ophthalmologists
  • Leadership Course to train future leaders of national ophthalmology societies affiliated with the PAAO
  • International advocacy efforts on your behalf
  • Opportunity to be published in PAAO’s peer-review scientific journal
  • An annual subscription to the multilingual scientific journal, Vision Pan-America
  • The monthly eVision online newsletter and updates from the President of the Board of Directors
  • An annual membership card and a certificate of membership in the Pan-American
  • An invitation to the PAAO cultural events which offer the opportunity to meet informally with colleagues and their families

To join or renew your membership, please visit