INSTRUCTIONS TO APPLICANT

Please print or type and complete application in its entirety. If answer is "none" or "not applicable," so indicate. If additional space is required, attach an addendum, properly identified.

DUES ARE COMPLIMENTARY

AOA #:______________________

Name:__________________________________________ Degrees:________________________

School Address:__________________________________________________________________

City:___________________________ State:_____ Zip:_______ Phone:(____)_______________________

Home Address:____________________________________________________________________

City:__________________________ State:_____ Zip:_______ Phone:(____)_______________________

Date of Birth:___________ Place of Birth:________________ Citizenship:_________________________

Social Security Number:_________________ Marital Status:___ Spouse's Name:_______________

Where You Intend To Practice______________Intended Practice Specialty___________________

EDUCATION

Premedical

School:____________________________________ City:______________________________________

Degree:________________________________________________________ Dates:__________________

Osteopathic School

School:____________________________________ City:______________________________________

Degree:________________________________________________________ Dates:_________________

OTHER AFFILIATIONS & INTERESTS

List All Membership/Affiliations with Civic, Fraternal, Political, Or Other Groups, Clubs, Organizations, Etc.:______________________________________________________________________________

__________________________________________________________________________________

Hobbies:___________________________________________________________________________

Talents:____________________________________________________________________________

Special Interests:____________________________________________________________________

(If you fly a plane, hold political office, have political aspirations; if you are a writer, artist, actor, collector, list these activities, interests.)

Indicate Your Chief Area Of Interest In Committee Or Other Work Of The Association:____________

___________________________________________________________________________________

Curriculum Vitae -- Optional. Please attach if possible. List all honors, awards & special recognitions.

CERTIFICATION BY APPLICANT

In making application for membership in the Delaware State Osteopathic Medical Society I agree to abide by the BYLAWS and the adopted Rules and Regulations of the Association.

I certify that the answers herein are complete and true to the best of my knowledge.

I hereby release from any liability, for statements made in good faith and without malice, all individuals who submit information at the request of the Association to facilitate the assessment of my qualifications for membership.

_____________________________
Date of Application

RECOMMENDED BY:

___________________________

Signature of Applicant

___________________________

_________________________________________
Signature of Dean or President

ADDITIONAL INSTRUCTIONS

To complete the processing of your application, the following attachments are requested:

1. Please have this application signed by the President or Dean of the College.

RETURN COMPLETED APPLICATION TO:

Delaware State Osteopathic Medical Society
P.O. Box 3315
Newport, DE 19804-4315