ASPO Membership Application

Professional Activities
Please list any and all professional activities, including academic and hospital staff appointments, from the completion of your training until present. You may add as many fields as needed by clicking the 'Save & add another' button.
Professional Activities
Academic Appointments
Hospital Staff Appointments*
Honors and Awards

Certification and Professional Society Affiliations
Are you certified by:*

American Board of OtolaryngologyRoyal College of Physicians and Surgeons of CanadaNot CertifiedOther
Year of Certification
Are you a Member of AAO-HNS?*

YesNo
Are you a member of an international equivalent to AAO-HNS (if applicable)?*

YesNo
Organization Name
Status / Membership Type
Please list any other Professional Societies or Organizations to which you belong:

You may add as many fields as needed by clicking the 'Save & add another' button.
Scientific and Professional Society Membership*
Please list the ASPO Meetings you have attended in the past three (3) years.

In order to be eligible for membership, applicants must have attended one ASPO meeting in the three years prior to application.
ASPO Meetings Attended*

References
A total of 2 reference letters are required for all Full and International Member Applicants.

*For current Fellow members, ASPO has retained the Fellowship Director letter submitted with your original application. If you would like to submit updated or additional letters you are welcome to do so, however, only one (1) additional Member Sponsor letter is required to complete your application.

*For International Members, if you did not complete a formal Pediatric Otolaryngology training program, please submit a letter from a local faculty member or mentor. Two ASPO Member Sponsor letters are also required.
Reference 1:

Director of your Pediatric Otolaryngology Fellowship Training Program
Fellowship Director Name
Pediatric Otolaryngology Fellowship Program Name
Reference Letter 1

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Reference 2:

ASPO Member
ASPO Member Sponsor #1 Name*
Reference Letter 2*

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Attachments and Application Fee
Bibliography of Publications*

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Please upload your CV*

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Certification*

By submission of this form I certify that all information in this application is correct.
How will you pay your application fee ($100):

CheckCredit CardInternational Membership application fee ($50)Fellow Member (no application fee required)
Check should be made payable in the amount of $100 to the following:

ASPO
c/o Associaiton Management
633 N. St. Clair
Chicago, IL 60611

Application Fee

Application Fee$100.00

International Application Fee$50.00

Credit Card Information

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

If you have any questions, please contact ASPO Headquarters at:

Phone: 312-202-5005

Email: aspo@facs.org
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