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Rhode Island Orthopedic Society - Membership Application
Thank you for your interest in joining the Rhode Island Orthopedic Society (RIOS)! Please fill out the form in its entirety and your application will be reviewed by the board of directors.
1.
First name:
2.
Last name:
3.
Middle name:
4.
Email:
5.
Date of Birth:
6.
Cell Phone:
7.
Business Phone:
8.
Name of Employer:
9.
Employer Address:
10.
Date Began Practice:
11.
Medical college name and dates attended:
12.
In what hospital did you serve as an intern:
13.
In what hospital did you serve as a resident:
14.
In what hospital did you serve as an assistant:
15.
In what hospital(s) are you a staff member and/or have teaching appointment (please list position(s))?
16.
Are you a member of:
The American Medical Association
The American College of Surgeons
American Academy of Orthopaedic Surgeons
Other (please specify)
17.
Please list the date your membership began as well as date of certification with the American Academy of Orthopaedic Surgeons (if applicable):
18.
Have you ever applied to any medical organization and been refused?
19.
In your personal opinion, is there any professional or person problem which would disqualify you from membership:
