Application for Full Membership

Board Certified Member Application

Basic Information

* Indicates required field

Name *

First

Last

Speciality *

Spouse/Partner Name *

First

Last

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Home Email *

Employment

Office Address *

Line 1

Line 2

City

State

Zip Code

Country

Office Contact *

Office Phone Number *

Work Email *

Indiana County Where Office is Located *

Training

Medical School *

Date of Graduation / Certification *

Residency Program and Location *

Fellowship Training and Location *

Fellowship Date *

Fellowship Type *

License

Date of Licensure in Indiana *

License Number *

Date of Certification by American Board of Orthopaedic Surgery *

Date of Certification by Osteopathic Board *

Application Sponsor

All applicants must have two sponsors to gain membership.

Name of Physician Sponsor 1 (Must be Current IO Society Member) *

Name of Physician Sponsor 2 (Must be Current IO Society Member) *

Applications and sponsor letters must be completed and mailed or faxed to the IOS office
no later than May 1.

Submit

OPTIONAL: PRINT AND MAIL OR EMAIL THE FORM

Mail or Email To:
Kellye Mitros
Interim Executive Director

Indiana Orthopaedic Society
P.O. Box 1221
South Bend, Indiana 46624

iosocietydirector@gmail.com
Tel: (574) 360-4154

PDF IOS Application - Board Certified
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WORD DOC IOS Application - Board Certified
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