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ASSOCIATION OF OTOLARYNGOLOGY ADMINISTRATORS (AOA) MEMBERSHIP DUES RENEWAL   If you would like to mail in your renewal form, download the form here: - Primary Members   -   Secondary Members First Name: MI: Last Name: Practice Name Title: # Locations Address Suite City State Select a State Alabama Alaska Alberta Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Zip Work Phone Ext Work Fax Email Web Site   I consider my practice setting to be: an academic practice a private practice owned by PPMC Vendor Practice Info (Check all that apply) OTO-HNS Facial Plastics SET/IDT ABR/ENG NP/PA CT Scanner Sleep Center EMR Neuro/Otology Pediatric only RAST Hearing Aids Surgery Center Clinical Research Vestibular Rehab Certified Number of FTE Physicians      Number of FTE Non-Physicians      I have knowledge/experience in the following areas (check all that apply) Website Development CPT/ICD9 Coding Policy/Procedure Development Journalism/Publishing Marketing/Advertising Legislative Activities Public Speaking Your membership will expire on December 31, 2009. Your name will be removed as a member of AOA as of January 31, 2009 unless renewed. Active-Primary Member $345 Membership category with full membership privileges; must be in a managerial capacity (business or clinical), in a private or academic medical practice in the field of otolaryngology. Active-Secondary Member $295 Membership category open to additional persons joining AOA from the same practice as an Active-Primary member. This category also has full membership privileges, and must be in a managerial capacity (business or clinical), in a private or academic medical practice in the field of otolaryngology. The fee reduction for additional members is the only difference between the two categories. In order to choose this category, either your physician or another members of your staff must be an AOA member. Physician membership in AAO-HNS is not sufficient. Name of Primary Member from your practice: Name of Managing Physician: AAO Member #: Associate Member $345 Non-voting, supportive member with no business responsibilities in a medical practice. PAYMENT OPTIONS Check Make check payable to AOA, attach the completed form and mail to the AOA. AOA 2400 Ardmore Blvd. Suite 302 Pittsburgh, PA 15221 Credit Card or eCheck (A link will be provided on the next page) For more information, contact the AOA at: 412.243.5156 - 412.243.5160 (FAX) AOA@oto-online.org 1.5% of dues are used for lobbying activity and not deductible for federal income tax purposes