American Academy of Otolaryngology Head and Neck Surgery

MEMBERSHIP APPLICATION

PERSONAL DATA

Please type or print clearly all information exactly as you wish it to appear in your Academy records.
Last name/surname/family name

First/given name

Middle initial

PROFESSIONAL MAILING ADDRESS (Listed in the Online Membership Directory, if no professional

address is provided, only your name will be listed in the directory)

Birth Year:
Ethnicity
African American
Asian

American Indian

Caucasian

Hispanic

Other____________
Institution/company name

Department

Gender:
Male

Street address Suite/room/apartment

City

State/province

Country

Phone (with area or country code)

ZIP/postal code

Fax (with area or country code)

Email address

Web address

PREFERRED MAILING ADDRESS

Street address Suite/room/apartment
City

State/province

Country

ZIP/postal code

Home Phone (with area or country code)

Mobile (with area or country code)

Email address

MEDICAL TRAINING
Please complete all information about your medical training, licensing, and board certification. This
allows us to tailor communications specifically to your interests.
Medical school (required)

Female

WHAT IS YOUR PRIMARY SUBSPECIALTY?

(SELECT ALL THAT APPLY):
ADM

Administrative

AU

Audiology

BE

Broncho-Esophagology

ENDO

Endocrine Surgery

FPS

Facial Plastic & Reconstructive Surgery

GEN

General Otolaryngology

HNS

Head and Neck Surgery

LRY

Laryngology

MXF

Maxillofacial Surgery

NRO

Neurotology

OAL

Otolaryngologic Allergy

OP

Otolaryngic Pathology

OTO

Otology

PDO

Pediatric Otolaryngology

RH

Rhinology

SBS

Skull Base Surgery

SM

Sleep Medicine

WHAT IS YOUR PRIMARY PRACTICE TYPE?

(SELECT ONLY ONE):
Solo

Name of School or Program

City and state/province

Group single specialty

Completion year

Degree(s) (e.g., MD, DO, MBBS, FRCS)

Residency training (required)

Group multi-specialty
Research
Clinical non-physician
Local/State/Federal Government/Military
Staff Model/HMO

Name of school or program

Hospital/Facility non-government
Non-clinical organization

City and state/province

Completion year

Not in active practice

Fellowship training (if applicable)

SECONDARY PRACTICE TYPE

From the list above, please select only one:

Name of school or program

WOULD YOU CONSIDER YOUR SETTING (SELECT ONLY ONE):

Type of fellowship (e.g., laser application, rhinology, clinical research)

City and state/province

Completion year

Name of school or program

Questions? Contact the AAO-HNS Member Resource Center

Private practice

Group practice

Resident/In-Training

LICENSING AND CERTIFICATION

Postgraduate degrees other than formal medical degree (if applicable)

Type of study

Academic

Degree(s) (e.g., MD, MBBS, FRCS)

Licensed to practice in:

United States

International

Canada

List state(s)/countries:

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American Academy of Otolaryngology Head and Neck Surgery

TRAINING VERIFICATION

Applicants applying for Member In-Training, Fellow In-Training, Resident

or Medical Student or enrolled in an accredited Medical School status
must complete this section.

AMA MEMBER:

YES

NO

ACS MEMBER:

YES

NO Year Elected: _____________

AMA Medical Education Number: __________________________________

If you are currently in a formal otolaryngology training/residency program,

the program chair or director is required to complete this section, or you
may attach a copy of your letter of acceptance, including beginning and
end dates of training.

>

certify that I am the chair/director of the training/residency program

shown below and that the applicant is currently enrolled in this
formal, approved otolaryngology training/residency program.
This is a (please check one):
Residency program
Fellowship training program
Accredited medical school program

Type of study (e.g., laser application, rhinology, clinical research)

Beginning year Expected completion year

>

Name of school or program

Signature of Program Chair/Director

NAME OF ANY OTHER CERTIFYING BOARD (ATTACH COPY OF CERTIFICATE):

APPLICANT NAME

>

By signing the endorsement for this applicant for membership in the

American Academy of OtolaryngologyHead and Neck Surgery, I certify
that I have personal knowledge of the applicant and I am familiar with the
applicants professional competence and conduct.

ENDORSER #1:

Signature

ENDORSER #2:

AAO-HNS ID number

Signature
Questions? Contact the AAO-HNS Member Resource Center

Society Memberships
AAA
AAFPRS
AAOA
AAP
ABEA
AHNS
ALA
TRIO
ANS
AOA
AOS
ARO
ARS
ASHA
ASPO
AADO
COS
NASBS
OCOO
SOHN
SUO

Please print your full name

Print full name

International Boards
RCSEd Royal College of Surgeons, Edinburgh
RCSAA Royal College of Surgeons, Australasian
RCSUK Royal College of Surgeons, England
RCSI Royal College of Surgeons, Ireland
RCSG Royal College of Surgeons, Glasgow

Date

STATEMENT OF ENDORSEMENT

AAO-HNS ID number

Year certified

RCSC Royal College of Physicians and Surgeons, Canada

US applicants must obtain two (2) endorsement signatures from active

AAO-HNS members or officers. *International applicants must obtain one
(1) endorsement signature from an active AAOHNS member or an officer
of their national society. Questions regarding this matter can be directed to
[email protected].

Print full name

Certification Board(s):
ABAI American Board of Allergy & Immunology
ABEM American Board of Emergency Medicine
ABFP American Board of Family Practice
ABFPRS American Board of Facial Plastic
& Reconstructive Surgery
ABIM American Board of Internal Medicine
ABOP American Board of Ophthalmology
ABOto American Board of Otolaryngology
ABNS American Board of Neurological Surgery
ABPM American Board of Preventive Medicine
ABPS American Board of Plastic Surgery
ABR American Board of Radiology
ABS American Board of Surgery
AMPAT American Board of Pathology
AMPED American Board of Pediatrics
AOBOO American Osteopathic Board
Otolaryngology & Ophthalmology

I, (Name of Program Chair/Director)

AAO-HNS ID#

MEMBERSHIP APPLICATION

American Academy of Audiology

American Academy of Facial Plastic and Reconstructive Surgery
American Academy of Otolaryngic Allergy
American Academy of Pediatrics
American Broncho-Esophagological Association
American Head and Neck Society
American Laryngological Association
American Laryngological, Rhinological, and Otological Society, Inc.
American Neurotology Society
Association of Otolaryngology Administrators
American Otological Society
Association for Research in Otolaryngology
American Rhinologic Society
American Speech-Language-Hearing Association
American Society of Pediatric Otolaryngology
Association of Academic Departments of Otolaryngology
Canadian Otolaryngology Society
North American Skull Base Society
Osteopathic College of Ophthalmologic Otolaryngology
Society of Otorhinolaryngology and Head-Neck Nurses
Society of University OtolaryngologistsHead and Neck Surgeons

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American Academy of Otolaryngology Head and Neck Surgery

MEMBERSHIP APPLICATION

Application requirements
Membership
category

Membership criteria

Fellow

Degree of MD or DO with a valid and unrestricted license to practice medicine

in the U.S. or Canada. Certified by a specialty board acceptable to the Board of
Directors.

Fellow/
Military/Gov
employee

Degree of MD or DO with a valid and unrestricted license to practice medicine

in the U.S. Employed by the U.S. armed forces or U.S. government agency.
Certified by a specialty board acceptable to the Board of Directors.

Member

Degree of MD or DO with a valid and unrestricted license to practice medicine in

the U.S. or Canada. Has completed three years of training in otolaryngologyhead
and neck surgery acceptable to the Board of Directors and is not board-certified.

Scientific
Fellow

PhD or equivalent degree in associated field including but not limited to audiology,
speech-language pathology, and neuroscience. Full or conjoint appointment on
an otolaryngologyhead and neck surgery faculty and participates in a residency
training program. This is a non-voting membership category.

Resident

Degree of MD or DO, or equivalent medical degree. Engaged in a full-time

otolaryngologyhead and neck surgery or other training program in the U.S.
or Canada. Residency status cannot exceed six years. This is a non-voting
membership category.

Fellow
In-Training

Degree of MD or DO with a valid and unrestricted license to practice medicine

in the U.S. or Canada. Engaged in a fellowship or postgraduate training program.
Certified by a specialty board accepted to the Board of Directors. In-Training
status cannot exceed two years.

Member
In-Training

Degree of MD or DO with a valid and unrestricted license to practice medicine

in the U.S. or Canada, but not board-certified. Engaged in a fellowship or
postgraduate training program. In-Training status cannot exceed two years.

Affiliate Medical
Student

Medical Student membership is for full-time students enrolled in an accredited

medical school program, and not eligible for any other type of membership in
the Academy. This is a non-voting membership category.

Affiliate Others

Not eligible for any other type of membership in the Academy, but supportive of
otolaryngologyhead and neck surgery. This is a non-voting membership category.

Associate

Degree of MD, DMD, or DDS and engaged in a field which is, in the view of the
Board of Directors, allied to otolaryngologyhead and neck surgery, and is not
eligible for any other type of membership in the Academy. This is a non-voting
membership category.

International
Fellow

Degree of MD or DO or equivalent practicing in a country other than the U.S.

or Canada with a valid and unrestricted license in his or her respective country.
Certified by a medical specialty board acceptable to the Board of Directors. This
is a non-voting membership category.

International
Member

Degree of MD or DO or equivalent and practicing in a country other than

the U.S. or Canada with a valid and unrestricted license in his or her country.
Completed three years of formal training in otolaryngologyhead and neck
surgery deemed acceptable to the Board of Directors. This is a non-voting
membership category.

International
Scientific
Fellow

Degree of PhD or equivalent in a field associated with otolaryngologyhead and

neck surgery including but not limited to audiology, speech-language pathology,
and neuroscience. Full or conjoint appointment on an otolaryngologyhead
and neck surgery faculty outside of the U.S. or Canada. This is a non-voting
membership category.

International
Resident

Degree of MD or DO, or equivalent and is engaged in a full-time otolaryngology

head and neck surgery training program acceptable to the Board of Directors and
located outside the U.S. or Canada. Residency membership cannot exceed six
years. This is a non-voting membership category.

International
Associate

Degree of MD, DMD, or DDS and is engaged in a field which is, in the view of the
Board of Directors, allied to otolaryngologyhead and neck surgery, and is not eligible
for any other type of membership. This is a non-voting membership category.

Retired

Retired membership is open to those who are age 65 or greater and are retired
from active practice by working twenty (20) hours or less per week. A member
must send written notice to the AAO-HNS Board of Directors and supply a copy
of their medical malpractice tail insurance coverage or other proof of retirement
as provided to their local medical licensing board for this class of membership to
be activated.

Questions? Contact the AAO-HNS Member Resource Center

[email protected] | www.entnet.org | 1-877-722-6467 or 1-703-836-4444

American Academy of Otolaryngology Head and Neck Surgery

MEMBERSHIP APPLICATION

MEMBERSHIP DUES:
Please check your dues amount. (Refer to member categories in the Membership Application Guidelines on pg. 3.)

U.S.

Canada

Fellow

$890

$590

$590

Fellow Military/
Government employee

$790

N/A

N/A

Member

$890

$590

$590

Scientific Fellow

$590

$590

$590

Resident

$100

$100

$100

Fellow In-Training

$100

$100

$100

Member In-Training

$100

$100

$100

Affiliate

$250

$250

$250

Associate

$890

$590

$590

Retired

$100

$100

$100

Medical Student

$100

$100

$100

I understand that if I choose wire transfer as my payment method I must add an additional $16 service charge.

Subtotal:
Total amount paid:

OFFICE MANAGER: If someone other than the applicant will handle billing, please indicate so here.
Full name
Email address

We cannot process your application until funds are received. Please check your method of payment:
Check

Money order

Cashiers check

VISA

MasterCard

AMEX

Wire transfer

Credit card number

Signature

Expiration date (MM/YY)

Name on credit card

Credit cardholders billing address

City

DOCUMENTATION REQUIRED

International
(Current membership fees as of 10/2014. *Subject to change)

Category

State

ZIP

Country

Membership Application
Copy of Current Medical License
2 Signatures of Endorsement
Verification Letters/Signatures
Bio/Curriculum Vitae
Payment

Make check, money order, cashiers

check, or draft payable on a U.S.
bank, in U.S. dollars, to the American Academy of
OtolaryngologyHead and Neck
Surgery. Payment must be enclosed with your application.

WIRE TRANSFERS ONLY:

To wire transfer funds to the AAOHNS, send to: Bank of America,
730 15th St NW, 2nd Floor, Washington, DC 20005-1012; Bank of
America, ABA # 026009593, Swift
# BOFAUS3N (please include your
full name on transfer and bank
charges). You must add an additional $16 to your total to account
for the Bank of America Service
charge.

PLEASE RETURN YOUR

COMPLETED APPLICATION TO:
American Academy of OtolaryngologyHead and Neck Surgery
ATTN: Member Service Center
1650 Diagonal Road
Alexandria, VA 22314-2857, U.S.A.
Fax: 1-7036844288
Email: [email protected]

AAO-HNS ETHICS STATEMENT

I certify that the above information is true and correct. I understand that any material false statement or misrepresentation (including omission
of fact) on this application or on any document used to secure membership can be grounds for rejection of my application or, if I am granted
membership, grounds for termination of my membership in the American Academy of Otolaryngology-Head and Neck Surgery. I understand if
accepted, I agree to abide by the AAO-HNS bylaws, member-related policies, and the Code of Ethics. I understand that by providing my mailing address, telephone number, fax and e-mail address, I consent to receive communications sent by or on behalf of the American Academy of
Otolaryngology-Head and Neck Surgery via regular mail, e-mail, telephone, or fax.

Signature of Applicant (REQUIRED)

Date

THANK YOU FOR YOUR SUPPORT OF THE AAO-HNS

WEB15
Questions? Contact the AAO-HNS Member Resource Center

[email protected] | www.entnet.org | 1-877-722-6467 or 1-703-836-4444