OOSS Membership Application 2011
*Fee:
$1,500.00 USD - Facility Membership (1-9 members) fewer than 1,000 procedures per year.
$2,500.00 USD - Facility Membership (1-9 members) more than 1,000 procedures per year.
$500.00 USD - International Facility Membership
 

 
*Primary Member:
  Name   Degree   Email
  President's Council Donor?
 

 
PRIMARY ASC FACILITY  
*Name:
*Address:
*City:  *State:   *Zip:
*Phone:   Fax:
BILLING CONTACT & INFORMATION  
*First:   *Last:
*Address:
*City:   *State:   *Zip:
*Phone:   *Email:  
 
    President's Council Donor?  

 
PRIMARY PHYSICIAN CONTACT  
*First:   *Last:
*Degree:  
 
    President's Council Donor?  

 

  
DIRECTOR OF NURSING  
*First:   *Last:
*Degree:  
 
    President's Council Donor?  

 

  
ASC FACILITY ADMINISTRATOR  
*First:   *Last:
*Email:  
*Phone:   *Fax:  
 
    President's Council Donor?  

 

  
ASC FACILITY MEMBER INFORMATION (Additional persons to be included in this membership)  
Physician Member:
  Name   Degree   Email
  President's Council Donor?
 
Physician Member:
  Name   Degree   Email
  President's Council Donor?
 
Physician Member:
  Name   Degree   Email
  President's Council Donor?
 
Physician Member:
  Name   Degree   Email
  President's Council Donor?
 
Physician Member:
  Name   Degree   Email
  President's Council Donor?
 
  Any member with a degree of Doctor of Philosophy, RN, or of professional standing, and engaged in a field allied to ophthalmology.  
Associate Member:
  Name   Degree   Email
  President's Council Donor?

 

Total
$ USD

* Indicates Required Fields


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