Connecticut Orthopedic Society

APPLICATION FOR MEMEBERSHIP

Membership Benefits | How to Join | Application for Membership
Pay Membership Dues | Membership to PAs

You can fill out this SECURE Online form or you can print, fill out and mail with your check or credit card info to:

Connecticut Orthopedic Society
Susan Schaffman - Executive Director
26 Riggs Avenue
West Hartford, CT 06107
P: (860)561-5205
F: (860)561-5514
E: sasshops@aol.com

MEMBERSHIP APPLICATION FORM
Scroll Down for RESIDENT APPLICATION

Name:

Practice Name:

Business Address:

City, Zip

Business Phone:

Fax:

E-mail:

Office Manager:

Home Address:

Home Phone:

MD/DO Degree From:

Year Obtained:

CT License No.:

Sponsor's Name

Sponsor's Address

Sponsor's Phone

Residency Training:

Month/Year Began:

For information only, not a condition of membership.
ABOS Board Certified Yes No
Member of AAOS Yes No

THIS SECTION TO BE COMPLETED BY RESIDENT/FELLOW APPLICANTS ONLY
Provide name, address of your residency program chairman, who certifies your qualification for election to membership.

Name:

Address:

Institution:

Projected Grad Date:

Program Chair:

Program Chair Phone:

Credit Card Information

Type of Card:
MC or Visa

Name on Card:

Account No.:

Expiration Date :

Amount billed to your account will be $250.00

Yes, charge my credit card each year (January) for the membership dues until I notify otherwise.

No, do not charge my credit card each year. I will issue a new credit card authorization each year.