Please complete the application below and mail with dues payment to:

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

Annual Dues Payment is $250.00 (checks payable to the Connecticut Orthopedic Society or complete credit card information for annual payment of dues)

Type of membership applied for:
           ___Active     ___Resident/Fellow (No Dues)

Name:____________________________________________________
Practice Name:______________________________________________
Business Address:___________________________________________
City___________________________________ Zip_______________
Business Phone:_____________________ Fax___________________
E-Mail:___________________________________________________

Office Manager:____________________________________________
Office Manager Email:_______________________________________
Home Address:_____________________________________________
Home Phone:______________________Date of Birth:______________

MD/DO Degree from:_______________________________________
Year Obtained:_____________________________________________
CT License No.:____________________________________________
Year Obtained:_____________________________________________

Sponsor’s Name____________________________________________
Sponsor’s Address___________________________________________
Sponsor’s Phone____________________________________________

Residency Training:__________________________________________
Mo/Yr Began:_______________ Mo/Yr Completed:________________

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, and signature of your residency program chairman, who certifies your qualification for election to membership.
Name:_____________________________________________________
Address:___________________________________________________
Institution:__________________________________________________
Projected Graduation Date:_____________________________________
Program Chair:_______________________________________________
Program Chair Signature:_______________________________________

Thank you for your application. If you have any questions, please call the Society’s Administrative Office at (860)561-5205.

Paying by Credit Card

Please charge my credit card in the amount of $250.00 annually* for membership dues in the Connecticut Orthopedic Society.

Mastercard or Visa (circle one)

Name on Account____________________________________________
Account Number_____________________________________________
Expiration Date_____________________________
____ 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.
Signature__________________________________________________