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ASSOCIATION OF OTOLARYNGOLOGY ADMINISTRATORS (AOA) — MEMBER APPLICATION

FIRST TIME NEW MEMBER'S SPECIAL
First Name:
 MI:
 Last Name:
Practice Name
 Title: # Locations
Address
 Suite
City
 State
 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
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
I authorize the AOA to contact me via email or fax
How did you learn about AOA?
MEMBERSHIP EFFECTIVE THROUGH DECEMBER 31, 2008
Active-Primary Member $250 $200
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 $200
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 $250
Non-voting, supportive member with no business responsibilities in a medical.
I understand that AOA memberships run concurrently with the calendar year and that, if not renewed, my membership will expire on December 31st. Applicants submitting a membership request after October 1st receive membership status for the balance of the current year plus the year starting January 1st.
PAYMENT OPTIONS
Check
Make check payable to AOA, attach the completed form and mail to the AOA lockbox.
AOA
P.O. Box 503269
St. Louis, MO 63150-3269
Credit Card (Only VISA and MasterCard accepted)
Fax completed form to 412.243.5160 or mail to: AOA Office
1844 Ardmore Blvd.
Pittsburgh, PA 15221
Card Number (no '-')
 Name as appears on card
VISA MasterCard Exp Date (MM/YYYY):
I agree to pay AOA the amount of $ for a one-year membership in AOA.
For more information, contact the AOA Office at: 412.243.5156  412.243.5160 (FAX) rwagner@cmemanage.com
1.5% of dues are used for lobbying activity and not deductible for federal income tax purposes
AOA 1844 Ardmore Blvd. Pittsburgh, PA 15221 - Phone:(412)243-5156 - Fax:(412)243-5160 - AOA@oto-online.org