Please read page 4 before filling out application
THE AMERICAN FRACTURE ASSOCIATION
Incorporated in the State of Illinois
FOUNDED —1938
APPLICATION FOR
MEMBERSHIP
.
Date
20
TO THE BOARD OF GOVERNORS of
THE AMERICAN FRACTURE ASSOCIATION:
I respectfully present my application for membership in The American Fracture Association and herewith submit the
following data for your consideration. If accepted I will pledge myself to abide by the Rules and Regulations governing this
medical society.
Please TYPE or PRINT entire form
Name
Office address
Email
City
State
Telephone
Fax
Residence address
City
State
Telephone
Fax
Age_
Zip Code
Zip Code
Place and date of birth
Marital status
Citizenship _______
1. Premedical Education
Name ol College or University
Years Attended
Degree and Date of
Graduation
Name
Type
Years of Service
2. Medical Education
3. Internship
and
Location of Hospital
4. Residencies
Name and Location of Hospital
Specialty
Years ot
Service
5. Certification by Specialty Name of Specialty Board
Boards
Date of
Certification
6. Other Specialty Training Name and Location
Dates
7. Present and Past Hospital Name and Location of Hospital
Affiliation
8. List all Medical Society
Memberships and
Fellowships.
Staff Position
Dates
9. Past and Present
Teaching Positions
Name of Institution
Faculty Position
Date
10. What percentage of your
practice is devoted to
fractures and other
musculoskeletal trauma.
11. Contributions to
Medical &
Surgical
Literature. Give
Subjects, Date
and Place of
Publication
List other books and articles and attach to application
Name of Reference
Complete Address
12. References. . .
List five, two of
which MUST be in
your city or state.
Give COMPLETE
address of each.
I hereby agree that I will abide by the action of the Board of Governors of The American
Fracture Association on the application and that if rejected, I will in no wise hold the said board of
Governors or The American Fracture Association legally responsible for such action.
Signature
MEMBERSHIP FEE — $100.00 (Refunded if application is rejected)
(Make check payable to The American Fracture Association)
PI wise TYPE or PRINT complete data, and mail with Membership Fee
to: AMERICAN FRACTURE ASSOCIATION
/Mfonso E. Wno M.0. 317
Peach
Dublin, TX 76446
Report of Membership Committee
Please submit two
recent Photographs
Action of Board of Governors
PHOTOGRAPH