| Application for Membership |
| Form must be printed and
submitted in hard copy: TYPE ONLY For best results, set all page margins to 0.5 inches. |
| Name |
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| Complete Mailing Address |
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| Business Phone | Fax | ||||
| Residential Phone | |||||
| Date of Birth |
| Academic Training | ||||
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| Pre-Dental or Pre-Medical | ||||
| Dental or Medical | ||||
| Graduate | ||||
| Post-Graduate List all short courses in last five years. Use additional page if necessary. |
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| Specialty Board Certification | |
| Teaching or Hospital Appointments | |||
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| Research Experience (list project, grant source if applicable) | |
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| * List papers, essays, clinics, or exhibits presented by you at dental or other professional meetings and the dates. | |
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| * List memberships in professional and scientific organizations (ADA, etc.) and offices held. | |
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| * Use separate sheet if necessary | |
| Names of two Active Fellows of the Academy from whom the Secretary may obtain an endorsement. | ||
| 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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IMPORTANT: Affix a recent 2" X 3" photograph.
[Do not write in these spaces.]
| Date Application received | |
| Approved/Rejected by | |
| Fellowship Committee | |
| Approved/Rejected by the Board of Directors | |
| Complete Form and Mail to:
Dr. Steven P. Haug Executive Secretary/Treasurer 1121 West Michigan Street Indianapolis, IN 46202 Tel: 317-274-5571 Fax 317-278-2818 Email: sphaug@iupui.edu |