New Members Applicationform
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A M E R I C A N A C A D E M Y O F M A X I L L O F A C I A L P R O S T H E T I C S 1 9 5 3 AMERICAN ACADEMY OF MAXILLOFACIAL PROSTHETICS APPLICATION FOR MEMBERSHIP Page 1 of 3 Personal Information: Name: DOB: [Last Name] [First Name] [Middle Initial] [Degrees] [MM/DD/YYYY] Mailing Address: Tel 1: [Street Address] [Business phone, please include Country Code] Tel 2: [Home phone, please include Country Code] Fax: [City] [State/Province] [Zip/Postal Code] [Country] [Please include Country Code] E-mail: Academic Training: Institution Degree Year Pre-Dental or Pre-Medical Dental or Medical Graduate Post Graduate List all short courses in last five years. Use additional page if necessary. Course Institution Degree Year Specialty Board Certification Form must be printed and submitted in hard copy: TYPE ONLY.
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Transcript of New Members Applicationform
AMERICA
N A
CA
DE
MY O
F MAXILLOFACIA
L P
RO
STH
ETICS
1953
AMERICAN ACADEMY OF MAXILLOFACIAL PROSTHETICS
APPLICATION FOR MEMBERSHIP Page 1 of 3
Personal Information:
Name: DOB: [Last Name] [First Name] [Middle Initial] [Degrees] [MM/DD/YYYY]
Mailing Address: Tel 1: [Street Address] [Business phone, please include Country Code]
Tel 2: [Home phone, please include Country Code]
Fax: [City] [State/Province] [Zip/Postal Code] [Country] [Please include Country Code]
E-mail:
Academic Training:
Institution Degree Year
Pre-Dental or Pre-Medical
Dental or Medical
Graduate
Post GraduateList all short courses in last five years. Use additional page if necessary.
Course Institution Degree Year
Specialty Board Certification
Form must be printed and submitted in hard copy: TYPE ONLY.
AMERICA
N A
CA
DE
MY O
F MAXILLOFACIA
L P
RO
STH
ETICS
1953
AMERICAN ACADEMY OF MAXILLOFACIAL PROSTHETICS
APPLICATION FOR MEMBERSHIP Page 2 of 3
Teaching or Hospital Appointments:
Institution Appointment MM/DD/YYYY
Research Experience (list project, grant source if applicable):
Research Project Grant Source MM/DD/YYYY
List papers, essays, clinics, or exhibits presented by you at dental or other professional meetings and the dates. Use separate sheet if necessary.
List memberships in professional and scientific organizations (ADA, etc.) and offices held.
Names of two Active Fellows of the Academy from whom the Secretary may obtain an endorsement.
AMERICA
N A
CA
DE
MY O
F MAXILLOFACIA
L P
RO
STH
ETICS
1953
AMERICAN ACADEMY OF MAXILLOFACIAL PROSTHETICS
APPLICATION FOR MEMBERSHIP Page 3 of 3
What is your purpose in wanting to join the Academy and in what capacity do you believe you can best serve the Academy?
If elected to membership in the American Academy of Maxillofacial Prosthetics, I agree to abide by the Constitution, By-Laws and other rulings of the Academy as well as such changes and amendments as may thereafter be properly adopted.
[Signature] [MM/DD/YYYY]
IMPORTANT: Affix a recent 2” X 3” photograph.
Date Application received: [MM/DD/YYYY]
Approved/Rejected By:
Fellowship Committee:
Approved/Rejected by the Board of Directors:
Complete Form and Mail to: Dr. Thomas Salinas 200 First Street SWRochester, MN 55905USA
Tel: (507) 284-3185Fax: (507) 284-8082
E-mail: [email protected]
[Do not write in these spaces]
