VOS Membership Application
CONTACT INFORMATION
Required fields denoted by
*
Required fields for students denoted by
†
Name
*
:
Title
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Mailing Address
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Billing Address
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Home Phone
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Work Phone
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Ext.
Fax:
Email
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Date of Birth:
/
/
(mm/dd/yy)
EDUCATION
Medical School
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Date of Graduation
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/
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Program Director’s email
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:
PRIMARY EMPLOYMENT
Please choose one or more of the following specialties
*
:
Hand
Elbow
Shoulder
Spine
Hip
Knee
Foot and Ankle
Pediatric
Sports
Trauma
Practice Setting:
Solo Private
Group Private
Multi-Specialty Private
Academic
Military
Hospital Privileges:
Has license to practice medicine ever been suspended or revoked?
Yes
No
If “yes”, explain:
Certification by American Board of Orthopaedic Surgeons
*
:
Yes
No
Year
Board Eligible
*
:
Yes
No
If “yes”, when will you take the examination? (year)
Part I
Part II
MEMBERSHIP CATEGORIES & ELIGIBILITY REQUIREMENT
Active
An Active member in the Virginia Orthopaedic Society shall be certified by the American Board of Orthopaedic Surgeons or the American Osteopathic Board of Orthopaedic Surgery and shall reside or maintain an office and practice orthopaedic surgery in Virginia. Active members have all rights and privileges in the VOS and may be elected to serve as officers or directors of the Society.
$350
Associate (A)
An Associate (A) member shall be .Board Eligible. in orthopaedic surgery. An Associate (A) Member shall have the right to vote and hold office in the Society.
$350
Associate (B)
An Associate (B) member may be an individual who is in the US Armed Forces and is engaged in the practice of orthopaedic surgery within any of the military medical installations in Virginia. An Associate (B) Member shall have the right to vote and hold office in the Society.
$250
Associate (C)
An Associate (C) Member shall be a physician, non-orthopaedic surgeon with an interest in musculo-skeletal care. An Associate (C) member will have no vote and will not hold office in the Society.
$200
Associate (D)
An Associate (D) member shall be a Physician’s Assistant or licensed Nurse Practitioner with an interest in orthopaedic surgery. An Associate (D) member must have an established relationship with and be sponsored by a current VOS active member. An Associate (D) member will have no vote and will not hold office in the Society
Sponsor Name
*
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Sponsor Email
*
:
$200
Associate (E)
As Associate (E) member shall be an orthopaedic practice administrator or manager. An Associate (E) member must have an established relationship with and be sponsored by a current VOS active member. An Associate (E) member will have no vote and will not hold office in the Society.
Dues are free for group bill practice administrators who have all practicing orthopaedic surgeons as members of the society.
Sponsor Name
*
:
Sponsor Email
*
:
$125
Associate (F)
An Associate (F) member shall be a Licensed Athletic Trainer Certified (ATC) with an interest in orthopaedic surgery. An Associate (F) member must have an established relationship with and be sponsored by a current VOS active member. An Associate (F) member will have no vote and will not hold office in the Society.
$75
Associate Resident
Currently enrolled in an approved residency program in orthopaedic surgery at an accredited medical school in Virginia. Associate Resident members pay no annual dues.
$10
Associate Fellow
Currently enrolled in an approved fellowship program in orthopaedic surgery at an accredited medical school in Virginia. Associate Fellow members pay no annual dues.
$10
Associate Medical Student
Currently enrolled in an accredited medical school in Virginia.
Free
PAYMENT INFORMATION
Card Type
*
:
Discover
MasterCard
Visa
Name printed on card
*
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Card Number
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Security Code
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Expiration Date
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Month
1
2
3
4
5
6
7
8
9
10
11
12
/
Year
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
Card Address
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Card Zip Code
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Electronic Signature
*
:
I certify that I meet the above criteria established for the category of membership for which I am applying and authorize the VOS to verify the accuracy of information provided.
