2011 Membership Registration

Please renew your membership in the Florida Orthopaedic Society by filling out the form below. 
* Items in red denote required fields.

Membership Categories:
Candidate Shall be doctors of medicine/osteopathy who are engaged full time in a Florida based AMA-approved orthopaedic surgery residency program and have completed the same; not yet eligible for associate membership.
Associate Shall be doctors of medicine/osteopathy licensed in Florida; have completed an AMA-approved orthopaedic training program; have been engaged in the exclusive practice of orthopaedic surgery for at least 2 years in the same locality in Florida.
Active Shall be doctors of of medicine/osteopathy licensed in Florida; have been engaged in the exclusive practice of orthopaedic surgery for at least 4 years in Florida; have been an associate for 2 years; and shall be certified by the American Board of Orthopaedic Surgery or the American Osteopathic Association.

Membership Status*

Member Name*

Main Practice Name*

Main Office Address*


City*

   

State*

Zip*

 Main Office Phone*

Main Office Fax 

Email Address*
Subspecialty
Administrator or Office Manager
 

 Voluntary Contributions:
FOPAC (Florida Orthopaedic Political Action Committee) - Dues Amt: $100.00
Legislative Action - Suggested Amt: $100.00
(Voluntary legislative action contributions will only be used to pay for direct lobbying expenses and PR pieces to support our legislative agenda.)
 Please enter amount here for Legislative Action Contribution:
 
Do you have a specific issue or interest that you would like to see the Society address?
  

Would you be interested in serving as a key contact for a legislator 
(state or federal) with whom you have a standing relationship?
If so, please list that legislator.

Credit Card Type*

Credit Card
 Number*

3 Digit Security Coder*

Credit Card Expiration*

 

Comments


COMMUNICATIONS CONSENT
I understand that by confirming my mailing address, e-mail address, telephone number, and fax number above, I consent to receive communications via regular mail, e-mail, telephone, and/or fax sent to that address/number above, on behalf of the Florida Orthopaedic Society and the Florida Orthopaedic Political Action Committee.

Please Note that the Revenue Reconciliation Act of 1993 states that association dues used for lobbying activities are not deductible as a business expense. As a result 35% of FOS membership dues and 100% of the voluntary legislative action and politcal action committee contributions cannot be deducted as a business expense for federal income tax purposes.
PLEASE NOTE:
For Active & Associate membership renewal, the above credit card will be charged $200.00.
For Candidate membership renewal, the above credit card will be charged $50.00
For voluntary contributions to FOPAC (Florida Orthopaedic Political Action Committee), $100.00 will be charged.
Renewal fees are non-refundable.
If you have any questions, please call (813) 948-8660


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