// Membership Application
UOS Membership Application
  1. To apply for Utah Ophthalmology Society membership, please complete the following information. We will notify you once the Utah Ophthalmology Society Board of Directors have reviewed your application.

  2. Biographical Data -------------------------------------------------------------------------------------------------------------------------------------------------------------

  3. Last Name
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  4. First Name
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  5. Middle Initial
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  6. Name of Practice
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  7. Primary Office Address
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  8. City
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  9. Zip Code
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  10. Home Address
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  11. City
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  12. Zip Code
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  13. Office Phone
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  14. Home Phone
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  15. Birth Date
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  16. Email Address
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    - For UOS business use only
  17. Languages Spoken
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  18. Gender
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  19. Marital Status
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  20. Citizenship
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  21. Spouse's Name
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  22. Spouse's Occupation
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  23. Education -----------------------------------------------------------------------------------------------------------------------------------------------------------------------

  24. Undergraduate College
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  25. Year of Graduation
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  26. Medical School
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  27. Degree
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  28. Year Graduated
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  29. Internship
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  30. Year Completed
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  31. Residency (Type & Place)
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  32. Year Completed
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  33. Graduate Training
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  34. Year Completed
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  35. Licensing/Certifications/Affiliations ------------------------------------------------------------------------------------------------------------------------------------

  36. Utah Medical License Number
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  37. Date of License
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  38. Board Certification (Board Name)
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  39. Date Completed
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  40. American Academy of Ophthalmology status
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  41. American Medical Association
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  42. Utah Medical Association
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  43. Other Medical Organization Memberships
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  44. Hospital Affiliations (active staff)
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  45. Two recommendations required: Please list 2 UOS member physicians who will recommend you for membership
  46. Recommendations
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  47. Date of Application
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  48. Category of Membership


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  49. By submitting this form I certify that I meet the above listed criteria established for the category of membership for which I am applying and authorize the UOS to verify the accuracy of information provided I certify that I am currently licensed as a physician in the state of Utah. I agree to abide by the UOS Bylaws.
  50. Captcha
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