APPLICATION FOR MEMBERSHIP - OHIO SOCIETY OF ORAL AND MAXILLOFACIAL SURGEONS
(A Component Society of the American Association of Oral and Maxillofacial Surgeons)
2241 GREENLAWN DRIVE, TOLEDO, OHIO 43614....Phone (419) 38203102
E-mail dfarley976@aol.com
1. Name____________________________________________________________Date of Appliation_____________
2. Address______________________________________________(office) Telephone # _______________
3. Date of Birth___________________________________________
4. PRE-DENTAL TRAINING________________________________________________ From _______ To_________
University Degree
DENTAL TRAINING __________________________________________________ From_________To ________
University Degree Year
POST GRADUATE ___________________________________________________ From _________To ________
University Degree Year
INTERNSHIP ___________________________________________________ From _________To________
Hospital City Year Year
RESIDENCY _____________________________________________________ From ________To_________
Hospital City Year Year
5. Member in good Local Dental Society_________________________________________________________
6. Admitted to membership in the American Association of Oral and Maxillofacial Suregons____________Year_______
7. Are you a Diplomate of the American Board of Oral and Maxillofacial Surgery?______________________
Year_________________
8. Number of years in limited practice____________________
9. Hospital Staff Appointments:
________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
10. Membership in other Oral and Maxillofacial Surgery Organizations.
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
11. Membership in Dental Societies:
______________________________________________________________________________________________________
________________________________________________________________________________________________________
12. I hereby apply for membership in the Ohio Society of Oral and Maxillofacial Surgeons and agree to abide by its
Constitution and By-laws as voted by the Membership
13. Please enclose current passport size picture
14. Recommendation from an active member of the Ohio Society of Oral and Maxillofacial Surgeons required.
Note sponsor below
____________________________________________________________________________________________________ Name Address Zip
15. First year's ldues of $150.00 is required with your application. Make check payament to Ohio Society of Oral and
Maxillofacial Surgeons.
I pledge myself as a member of the Ohio Society of Oral and Maxillofacial Surgeons to preseve
to the best of my ability the honor and dignity of the specialty of Oral and Maxillofacial Surgery.
I will be bound by impartial ethical oblications to those patients who shall entrust themselves to me,
and I will abide by this obligation in my relations with my colleagues and with the Society at large.
I pledge myself to refrain from all practice that may bring disrepute or discredit the specialty in which
I am a member. I shall enter into no contractual membership of a commercial or professional nature
contrary to the highest ideals of professional nature contray to the highest ideals of professional and
ethical practice.
I pledge that I shall contribute in all ways within my competence to public welfare by participation in and
contribution to educational, scientific and professional advancement of oral and maxillofacial surgery.
In solemn affirmation of declaration and conscientious duty to humanity I adopt this Pledge under God.
_______________________________________________________
Signature
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