NORTH CAROLINA SOCIETY OF EYE PHYSICIANS AND …
|North Carolina Society of Eye Physicians and Surgeons |
|2008 New member/renewal Application |
|Applicant Information |
|(if renewing and all contact information is the same please indicate “same” and return form with fee) |
|Name: |Board Eligible? Yes___ No____ |Board Certified? Yes___ No____ |
|Date of birth: |NCMB License No.: |Certification date: |
|Preferred mailing address: |
|City: |State: |ZIP Code: |
|Email: |Fax: |Add to Mailing List: Yes___ No____ |
|Have you ever been a NCSEPS Member? Yes___ No____ |Date of previous membership: From ________ to _________ |
|Medical EDUCATION Information |
|Medical School |Graduation Date: |
|Pre Med |From ________ to _________ |
|Internship |From ________ to _________ |
|Practice Since Residency |From ________ to _________ |
|Current Practice |How long? From ________ to _________ |
|Business information |
|City: |State: |ZIP Code: |
|Phone: |Fax: |Billing address? Yes___ No____ |
|Membership type (Please check one): |
|Active/Renewal |
|Yes____ No____ |Please provide explanation on a separate sheet and return with application. |
|professional affilations |
|1 |2 |3 |
|Hospital affiliations |
|1 |2 |3 |
|Please list the names of two sponsors who are active members of the society. The NCSEPS will need to obtain the signatures and letters of recommendation from these|
|sponsors. |
|Please include with your response along with the fee. |
|Name |Date |
|Name |Date |
|Payment information |
|Check enclosed ( |Check No.: _____________ |Please Invoice My Billing Address ( |
|Visa ( Exp. Date: ____________ |No: ______-_______-_______-_______ |3 Digit Code on Back: ____ ____ ____ |
|MC ( Exp. Date: ____________ | |Name on card:_________________________________ |
|Applicant Signature |
|I authorize the verification of the information provided on this form and declare that all information on this form is accurate and truthful. |
|Signature of applicant: ___________________________________________________ |Date: ___________________ |
01/29/08 2008 NCSEPS Application for Membership and Renewal
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