MD MEMBERSHIP APPLICATION
  1. You can fill out this SECURE Online form or you can print, fill out and mail with your check or credit card info to:

    Connecticut Orthopaedic Society
    Susan Schaffman - Executive Director
    26 Riggs Avenue
    West Hartford, CT 06107
    P: (860) 690-1146
    F: (860) 955-1178
    E: ctorthoexec@gmail.com
  2. Member of AAOS
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  3. First Name(*)
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  4. Last Name(*)
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  5. Business Address:(*)
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  6. Practice Name:(*)
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  7. City, State Zip:(*)
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  8. Phone:(*)
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  9. Fax:
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  10. Email:(*)
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  11. Office Manager:
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  12. Home Address:(*)
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  13. Home Phone:(*)
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  14. MD/DO Degree From:(*)
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  15. Year Obtained:
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  16. CT License No.:(*)
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  17. Sponsor's Name:
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  18. Sponsor's Address:
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  19. Sponsor's Phone:
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  20. Residency Training:
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  21. Month/Year Began:
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  22. For information only, not a condition of membership.
  23. ABOS Board Certified
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  24. THIS SECTION TO BE COMPLETED BY RESIDENT/FELLOW APPLICANTS ONLY Provide name, address of your residency program chairman, who certifies your qualification for election to membership.
  25. Resident Name:
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  26. Address:
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  27. Institution:
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  28. Projected Grad Date:
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  29. Program Chair:
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  30. Program Chair Phone:
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  31. COS Membership Application fee is $295.00
  32. To help prevent spam please Enter the Numbers(*)
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