M E M B E R S H I P    A P P L I C A T I O N

Illinois Society of Oral and Maxillofacial Surgeons
222 E. Wisconsin Avenue, Suite 214    Lake Forest, Illinois 60045
Phone (847) 482-0222, FAX (847) 482-0410

First Name_______________________ Middle ___________ Last ______________________________

Home Address__________________________City_____________________ST _______ Zip_________

Home Phone ( _______ ) ________________________________

Primary Office __________________________City_____________________ST________Zip_________

Office Phone _______________________________ Office Fax _________________________________

Please list other offices with address and phone and fax numbers on another sheet.

Email Address _________________________________ (at ____ Home ____ Work _____ Both)

Date of Birth _______________________ Place of Birth ________________________________

List Names of Your Current Practice Associates:

_____________________________________ _____________________________________

_____________________________________ _____________________________________

Pre-dental College ________________________________ Location ____________________________

Date of Graduation ____________________________ Degree _____________________________

Dental School ________________________________________________________________________

Date of Graduation ____________________________ Degree _________________________________

Location of Oral & Maxillofacial Internship __________________________________________________

Address ______________________________________ Dates of Attendance _____________________

Location of Oral & Maxillofacial Residency _________________________________________________

Address ______________________________________ Dates of Attendance _____________________

Additional Training ____________________________________________________________________

State of Illinois Dental License Number ________________________ Date Issued ________________

Other State License Number(s) and Dates Issued: ________________________________________

__________________________________________________________________________________

Is your practice limited exclusively to Oral and Maxillofacial Surgery? _________________________

Number of years ________________ Anesthesia Permit Number _____________________________

Is this your first application for ISOMS membership? _____ Yes _____ No (if "no", explain on separate sheet)

Are you a member of _____ ADA _____ AAOMS (Required) Date you joined __________________

ISDS Component Branch ______________________________________

Other Dental or Medical Societies to which you belong _______________________________________

_____________________________________________________________________________________

Are you a diplomate of the American Board of Oral and Maxillofacial Surgery? _____ Date __________

Do you teach any branch of Oral and Maxillofacial Surgery in a dental or medical school? __________

Name of School ________________________________ Position ______________________________

Date of Appointment _____________ Department Head _____________________________________

Current Hospital Affiliation(s)

Hospital ____________________________ City __________________ Position _____________________

Hospital ____________________________ City __________________ Position _____________________

Hospital ____________________________ City __________________ Position _____________________

I hereby pledge as conditions of membership in the Illinois Society of Oral and Maxillofacial Surgeons (ISOMS) to

• pursue my calling with strict regard for the ethics of my profession;
• place the welfare of my patients above all else;
• endeavor constantly to advance in knowledge by study, interchange of thought and attendance at clinics and Society meetings;
• regard scrupulously the interests of my professional colleagues and render willing help to them commensurate with services rendered;
• avoid the division of fees in any form, either by collecting fees for others referring patients to me or by permitting them to collect my fees for me, or in any way compensating any person referring patients to me.
• support the Constitution and Bylaws of ISOMS

I understand that if I violate this pledge or do not live up to the code of professional ethics, my name will be dropped from the membership rolls of ISOMS, and that the Certificate of Membership remains the property of ISOMS and must be returned when requested. I also understand that an office anesthesia evaluation is required prior to attaining active membership status and that periodic re-evaluation is a requirement for continued membership.

In consideration of ISOMS processing my application for membership, I grant permission and consent for the Society to obtain information regarding hospital staff privileges and actions relating thereto and all information from former and present professional society affiliations, specialty organizations, schools and other organizations providing professional training.

I hereby affirm and represent that the information contained in this application is true to the best of my knowledge. I expressly grant the ISOMS the authority to communicate and share any and all the foregoing information with any person or entity as the Society deems appropriate.

Signature _________________________________________________ Date ________________________

Applications must be sent to ISOMS with the $50 Application fee, the $50 Anesthesia Evaluation fee and the $175 annual dues. (One check for $275 made out to ISOMS is acceptable.)