Membership Application

To apply for membership to join the Chicago Laryngological and Otological Society, please fill out the form below completely.
Note that if you do not have a online CV you will need to submit it by email to: mreuter@nm.org
(For mail in applications please Download PDF and follow the included instructions)

NAME *
NAME
IF BOARD ELIGIBLE, THEN “ASSOCIATE” MEMBERSHIP IS CONSIDERED IF BOARD CERTIFIED, THEN “FULL” MEMBERSHIP IS CONSIDERED
DATE OF BOARD CERTIFICATION
DATE OF BOARD CERTIFICATION
(IF APPLICABLE)
PERSONAL INFORMATION
DATE OF BIRTH *
DATE OF BIRTH
RESIDENCE *
RESIDENCE
PHONE *
PHONE
FAX
FAX
EDUCATION
Date Degree Received:
Date Degree Received:
Date Degree Received:
Date Degree Received:
(INCLUDE DATES AND FELLOWSHIP TRAINING)
DATE OF ILLINOIS LICENSE TO PRACTICE MEDICINE: *
DATE OF ILLINOIS LICENSE TO PRACTICE MEDICINE:
DATE CERTIFIED BY THE AMERICAN BOARD OF OTOLARYNGOLOGY: *
DATE CERTIFIED BY THE AMERICAN BOARD OF OTOLARYNGOLOGY:
BOARD ELIGIBLE
ORIGINAL CONTRIBUTIONS TO THE MEDICAL LITERATURE. Please provide web link to digital CV or respond to the confirmation email with a copy of your CV
http://
UPON MY HONOR I CERTIFY THAT THE ABOVE PERSONAL INFORMATION IS CORRECT, THAT I AM A UNITED STATES CITIZEN OR LEGAL RESIDENT, AND THAT I SUBSCRIBE TO THE CODE OF ETHICS AND TO THE PRICIPLES OF THE AMERICAN COLLEGE OF SURGEONS AND THAT I HAVE NEVER ENGAGED IN ANY UNETHICAL PRACTICE.
THIS APPLICATION IS SPONSORED BY THE FOLLOWING TWO ACTIVE MEMBERS OF THE SOCIETY.