Apply for Active Membership - American Academy of Oral and Maxillofacial Radiology

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Apply for Active Membership

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Complete the following application for consideration of Active Membership in the AAOMR.

Please note that you will need to upload the the following documents:

1) Two letters of sponsorship from current Active members in the AAOMR

2) An electronic copy of your board or specialty certificate

3) Your CV

4) A copy of your dental certificate.

New Active Member Dues

United States $450.00
- includes annual dues and journal subscription ($450.00)

Outside the United States $450.00
- includes annual dues and journal subscription ($450.00). International postage is included.

Once your application is received, it will be reviewed. Once approved, you will receive an email outlining the steps you need to take to register online and pay your membership dues and journal postage if applicable.

Membership Application

Items with the (*) red asterisk are required and underlined items offer additional information about how to answer the particular field by scrolling over them.

1) PERSONAL INFORMATION
Asterix (*) areas require completion; underline areas describe format of contents
Title *		First Name *
Middle Name		Last Name *
Affiliation/Company *
Address Line 1 *
Address Line 2
City *
Location (State/Province/County) *
Zip/Postal Code
Country *
Telephone (Main) *		Telephone (Home)
Fax		E-mail *
Date of Birth *mm/dd/yyyy		Gender	Male Female
2) Sponsor Information
Active membership application requires submission of the names of two current Active members who will provide "Letters of Sponsorship" for the applicatant,
1st Referee's Name *		1st Referee's E-mail Address *
Upload 1st Referee Letter
2nd Referee's Name *		2nd referee's e-mail address *
Upload 2nd Referee Letter
Professional Information
In this Section your are required to provide information to verify your application for "Active" Membership status.
Name of OMRF Board *	American Board of OMR Canadian Board of OMR Japanese Board of OMR Other OMR Certifying Board Based on OMR achievement
Upload Certificate *Use the link to upload a digital copy of Board Certificate (Image [JPEG or Tiff] or PDF)
Achievements in OMRIf applying for active membership based on appreciable achievement of education, training, research, experience, etc. in OMR, list briefly such achievements. If based on Board status enter "Not applicable"
Professional awards/honorsList honors or awards related to professional experience
Office Positions HeldList elected or appointed offices held in professional/ academic organizations
Upload Curriculum Vitae *
Professional History
In this section you are required to provide details of educational background and training.
Current PositionEnter current academic status
Institution/Company
Proportion in OMREnter % effort in either the practice, teaching and research of OMR
Primary Degree *	DDS / DMD MD BDS MS
Primary Degree InstitutionEnter the University that awarded the Primary degree
Upload dental certificate *DDS, DMD or equivalent diploma
Other Advanced TrainingEnter any additional degrees awarded and awarding Institution (e.g. University of Xxxttyyy [MS])
Advanced OMR Training *Enter degree obtained, awarding Institution and Year confired (e.g. University of Texas Health Science Center at San Antonio, MS, 1987)
Non-US address? *If you wish your free OOOOE journal to be shipped to an international address, please choose "Yes", then proceed to the online store to purchase postage ($30).	Yes No

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