Contact

Tammi Connell, Executive Director
Michigan Orthopaedic Society
517.899.1304
execdir@miorthosociety.org

MOS MEMBERSHIP APPLICATION - 2022

Your application will be reviewed by the Board of Directors at the next meeting after receipt. Vote of membership for final acceptance occurs at the MOS Annual Scientific Meeting in June or at the fall general membership meeting.

* Required information

APPLICANT INFORMATION:

* First Name:
* Last Name:
* Date of Birth (format: mm/dd/yyyy):
* Home Address:
* City:
* State:
* ZIP Code:
* Cell Phone:
* Email Address:
* Confirm Email Address:
*
Membership Type:
- Active (Must be board certified)
- Associate
- Candidate (Resident)
- Advanced Practice Professional (APP)
- Emeritus (for Active Members who are 65, or Active Member for 25+ years and retired)

BUSINESS INFORMATION:

* Name of Business:
* Business Address:
* City:
* State:
* Zip:
* Office Phone:
* Specialty:
*
Practice Status:
- Solo
- Institution
- Associates

EDUCATION:

Medical School:
Residency and Year Completed:
Fellowship:

MEMBERSHIP INFORMATION:

*
Eligible ABOS (MD) or AOBOS (DO)
- Yes
- No
Date of Eligibility (format: mm/dd/yyyy):
*
Certified ABOS (MD) or AOBOS (DO)
- Yes
- No
Date of Certification (format: mm/dd/yyyy):
*
Member of AAOS (MD) or AOA (DO):
- Yes
- No
Date of Membership Expiration (format: mm/dd/yyyy):
Please list TWO members of the MOS for your required letters of recommendation so that we may contact them on your behalf. Only ONE of these members may be associated with you in practice.
* MEMBER NAME:
* MEMBER NAME:

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