Houston Ophthalmological Society
Membership Form
Houston Ophthalmological Society Membership Form
First Middle Last
Home Address
City
State Zip
Office Address
Office Phone
Office Fax
Email
This email is required for HOS communication and will not be displayed for public use.
AAO#
Date of Birth
Current Status with American Board of Ophthalmology:
Diplomate (Date of Certification: ) ABO Application Submitted No ABO Application Pending
Please note that this application must be accompanied by:
1. The names of two Regular members of the Houston Ophthalmological Society who have agreed to endorse your application.
2. A letter of certification of completion of 36 months of formal residency training in ophthalmology from the Director of the training program. (Send via email after submitting this form. Instructions to follow.)
3. A suitable photograph of head and shoulders made within the past three years. (Send via email after submitting this form. Instructions to follow.)
