Application for Membership
Form must be printed and submitted in hard copy; TYPE ONLY.
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1. Name: __________________________________________________________
               [LAST NAME],     [FIRST NAME]   [MIDDLE INITIAL]  [DEGREES]
   
   
2. Complete Mailing Address:
   
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3. Business Phone: (_____) __________ Residential Phone: (_____) _________
   
   Fax:(_____) ___________ E-mail: ___________________________________
   
   
4. Date of Birth: ________________________
   
   
5. Academic Training.
   
   
   1. Pre-Dental or Pre-Medical: ___________________________________
                                                      [INSTITUTION]    [DEGREE]    [YEAR]
      
   2. Dental or Medical: __________________________________________
      
      
   3. Graduate: _________________________________________________
      
      
   4. Post-graduate. List all short courses in last five years. Use additional page if necessary.
      
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      [COURSE]     [INSTITUTION]     [INSTRUCTOR]     [YEAR]
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6. Specialty Board Certification:
   
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7. Teaching or Hospital Appointments:
   
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    [INSTITUTION]     [APPOINTMENT]     [DATES]
   
   
8. * Research Experience (list project, grant source if applicable)
   
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9. * List papers, essays, clinics, or exhibits presented by you at dental or other professional meetings and the dates:
   
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10. * List memberships in professional and scientific organizations (ADA, etc.) and offices held:
    
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    * Use separate sheet if necessary
    
    
11. Names of two Active Fellows of the Academy from whom the Secretary may obtain an endorsement.
    
    
    1. ___________________________________________________________
       
       
    2. ___________________________________________________________
       
       
12. What is your purpose in wanting to join the Academy and in what capacity do you believe you can best serve the Academy?
    
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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.

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[APPLICANT'S SIGNATURE]                         [DATE]

IMPORTANT: Affix a recent 2" X 3" photograph.

[Do not write in this space.]  

Date Application received: _______________________________________________

Approved/Rejected by ___________________________________________________

Fellowship Committee: ___________________________________________________

Approved/Rejected by the Board of Directors: _______________________________