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Online Membership Application

Fields marked with an asterisk (*) are required.

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Type toa email address into the box below:


[We apologize for this step, but it prevents TOA from getting too much junk email]

Full Name*

Type of Membership Requested
Resident
Provisional (standard for practicing ophthalmologists)
Military
Out-of-State
Senior Associate

Personal Information

Spouse's Name

Office Address*

City State Zip
Country

Office Phone*

Office Fax

TOA often communicates with members via fax, so it is important that we have your fax number. However, since TOA sends faxes at any time of day or night, please do not enter a home fax number that rings aloud at night as we do not want to disturb you.

Home Address*

City State Zip
Country

Home Phone

Preferred Mailing Address*
Office
Home

E-mail Address

Date of Birth (mo/day/yr)*

Place of Birth*

Education

Degree*
Medical Doctor
Doctor of Osteopathic Medicine

Medical School*

Month and Year of Graduation*

Internship Hospital*

Dates of Duration*

Residency Hospital(s)*

Dates of Duration*

The TOA will contact your office to request a copy of your Residency certificate. (Those applying for Resident membership are asked to submit a letter from the chair of the ophthalmology department verifying their status as a resident.) You may send it right away if you wish. The TOA fax number is (512) 370-1637.

Special work in Ophthalmology (Fellowships)

Are you Board Certified (American Board of Ophthalmology)?*
Yes
No
If so, date of certification

Medical License Number and State of Licensure*
Number
State or Country

AAO Member Number*

Et Cetera

Notes, Comments, Special instructions, etc.

Legalese

I have limited my work to (specialty) since (year).

I certify that the above information is true. I hereby apply for membership in the Texas Ophthalmological Association, and, if elected, agree to abide by its Constitution & Bylaws.

By checking this box, I further agree that I submit this electronic application in lieu of a signed paper application.

Thank you for your interest in TOA and your commitment to your profession.

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This site opened on Friday, November 14, 1997. If you have suggestions for improvements, please fill out our online comment card, or send email to toa [at] TxEyeNet [dot] org>.

Texas Ophthalmological Association
toa[at] TxEyeNet [dot] org
401 West Fifteenth Street
Suite 825
Austin, Texas 78701-1665
(512) 370-1504
Fax (512) 370-1637

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