OSOMS Membership Application

Contact Information

First Name
Middle Name
Last Name Suffix/Degree
Primary Email
Date of Birth ?
 
Office Name
Office Address
 
City State Zip
Office Phone
Website
Office Contact
 
Secondary Office Address
 
City State Zip
 
Home Address
 
City State Zip
Home Phone Mobile
 
Please send all OSOMS correspondence to my (CHOOSE ONE):
Home
Primary Office
Secondary Office
 
Referral Directory Listing
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Education

Pre-Dental:
Training University
Degree
Years Attended
 
Dental:
Training University
Dental Degree
Years Attended
 
Post Graduate:
University
Degree
Years Attended
 
Internship Hospital
City Year Range
 
Residency Hospital
City Year Range
 

Memberships

Local Dental Society
American Association of Oral and Maxillofacial Surgeons
Admitted
Year
Diplomat of the American Board of Oral and Maxillofacial Surgery
Admitted
Year
Membership in other Oral and Maxillofacial Surgery Organizations
Membership in Dental Societies

Hospital Staff Appointments
Number of years in limited practice:
 

Sponsor

Recommendation from an active member of the Ohio Society of Oral and Maxillofacial Surgeons required.
Sponsor Name
Address
City State Zip
 

Membership Fee

MEMBERSHIP FEE
First year's dues of $150 is required with your application. NOTE: First year's dues are waived for new members who just completed their residency.
 
I hereby apply for membership in the Ohio Society of Oral and Maxillofacial Surgeons and agree to abide by its Constitution and By-laws as voted by the Membership.
I pledge myself as a member of the Ohio Society of Oral and Maxillofacial Surgeons to preserve to the best of my ability the honor and dignity of the specialty of Oral and Maxillofacilal Surgery. I will be bound by impartial ethical oblications to those patients who shall entrust themselves to me, and I will abide by this obligation in my relations with my colleagues and with the Society at large.
I pledge myself to refrain from all practice that may bring disrepute or discredit the specialty in which I am a member. I shall enter into no contractual membership of a commercial or professional nature contrary to the highest ideals of professional nature contrary to the highest ideals of professional and ethical practice.
I pledge that I shall contribute in all ways within my competence to public welfare by participation in contribution to educational, scientific and professional advancement of oral and maxillofacial surgery.
In solemn affirmation of declaration and conscientious duty to humanity I adopt this Pledge under God.
E-Signature
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