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

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Apply for Affiliate Membership

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

New Affiliate Member Dues

First year annual dues ($175.00)
Subscription to the scientific journal of the AAOMR, OOOO 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. At this stage you will also have the opportunity to purchase a 1-year subscription to OOOO.

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
Affiliate membership application does not require submission of a "Letter of Sponsorship" for the applicatant.
3) Professional Information
In this Section your are required to provide information to verify your application for "Affiliate" Membership status.
Primary Professional ActivityDescribe your position as it relates to your interest in the practice, education or research in OMR.	Dental Practice - GP Dental Practice - OMFS Dental Practice - Periodontics Dental Practice - Endodontics Industry - Sales Industry - Research Dental Practice - Oral Medicine Industry-corporate Dental Practice-Orthodontics Dental Practice - Pathology Dental Practice - Prosthodontics Other
Office Positions HeldList elected or appointed offices held in professional/ academic organizations
Professional History
In this section you are required to provide details of educational background and training.
Current PositionEnter current status.
Institution/CompanyEnter your current Employer's name
Proportion in OMREnter % effort in either the practice, teaching and research of OMR
Primary Degree *
Primary Degree InstitutionEnter the University that awarded the Primary degree
Other Advanced TrainingEnter any additional degrees awarded and awarding Institution (e.g. University of Xxxttyyy [MS])
Other OMR Experience *Describe any experience or training as it relates to OMR.
Special Comments
Supporting documentsCV, AAOMR Award cover letter, certifications, etc. (this field is not required).

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