RETINA SOCIETY MEMBER APPLICATION

NOTE: Before you begin, please ensure that you have completed the membership application (see below), you have a current CV to include and you have 3 papers to attach to this form as you may not submit unless you have all these documents.

Application (Word format) Application (PDF)

You must also include 2 current Active members of the Retina Society as sponsors that know you and will support your application.

Fields marked * are required.

Membership Category:

   Active     Corresponding     Associate

First Name: 

*

Middle Name:

*

Last Name:

*

Degrees:

Address:

*

Address 2:

City:

*

State/Prov.:

Postal/Zip:

*

Country:

Phone:

*

Fax:

*

Email:

*

Address:

Phone:

Email:

Preferred Contact:

Home    Office *

Citizenship:

Marital Status:

*

Name of Spouse:

First Sponsor:

Second Sponsor:

APPLICATION DOCUMENTS

Member Application:

Curriculum Vitae:

Pertinent Paper 1: *

Pertinent Paper 2: *

Pertinent Paper 3: *