New Members – Ophthalmological Society of the West Indies

PERSONAL INFORMATION

First Name*

Last Name*

Middle Initial*

Title*

If choose other for title then enter it here:

Mailing Address for all OSWI correspondence

Street Address*

City*

State/Province*

Country*

Zip Code*

Contact Number

Office Phone Number

Home Phone Number

Mobile Number

Office Fax Number

E-mail Address

Gender

Date Of Birth

UNDERGRADUATE MEDICAL TRAINING:

Name of Medical School*

Country*

City and State (US)*

Degree*

Month*

Year*

POSTGRADUATE TRAINING IN OPHTHALMOLOGY:

Name of Institution*

Qualification*

Country*

City and State (US)*

Director/Chair Name*

Beginning Date*

Completion Date*

FURTHER TRAINING IN OPHTHALMOLOGY

Name of Institution*

Qualification*

Country*

City and State (US)*

Director/Chair Name*

Type of Study*

Beginning Date*

Completion Date*

LICENSING AND CERTIFICATION

Do you have a valid and unrestricted license to practice ophthalmology?*

If no, explain

Which Country

STATEMENT OF ENDORSEMENT

Applicants applying for Membership must obtain endorsement from two (2) active Ordinary Members. Email from 2 active ordinary members or signed letter will be accepted.

Below are notes to Active members wishing to endorse new member application

By signing the endorsement for this applicant for Membership in OSWI, I certify that I am an active Ordinary Member of the Society and that I have personal knowledge of the Applicant and am familiar with the Applicant’s professional competence and conduct.

Full Name*

Signature

Date

Full Name*

Signature

Date

PRACTICE RESTRICTIONS (M)

Have you been convicted of a felony within the last five years?

If Yes then explain fully:

Have you had your licence to practice medicine suspended or revoked?

By signing and submitting this application, I agree that I have read and fully understood it and that all information submitted on or in support of this application is true, accurate, and complete. I understand and agree that all such information is subject to review and verification by or under the supervision of the Executive of OSWI.

Signature of Applicant*

Date

UPLOAD DOCUMENTS

Medical training documents*

Ophthalmology training certificates*

Licensing to practice certification