TxEyeNet.org Online Membership Application New! Find an Eye MD Online Member Directory Search TxEyeNet Home TOA Home Page General Information About Ophthalmology and the TOA Membership Information For Ophthalmologists Wishing to Join Benefits of Membership Types of Membership Apply for Membership Online Application Form Downloadable Application Form (pdf) Members Only Section Resources Exclusively for TOA Members TxEyeNet/capitol Legislative Information Internet Links Ophthalmic Practices and Resources Calendar Ophthalmic Events of Interest Site Guide TxEyeNet Navigation Made Easy Feedback Questions, Comments, Suggestions indicates current page Online Membership Application Fields marked with an asterisk (*) are required. SPAM PREVENTION: Type 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. Search Our Site   Search All TxEyeNetSearch Members AreaSearch TOA NewslettersSearch TOA Archives   Find ANY wordFind ALL words Find EXACT phrase  Help Search engine provided by PicoSearch Please read our Disclaimer. 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