Section on Cornea, Contact Lenses and Refractive Technologies Application for Diplomacy (PDF document)
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DATE______________________
Indicate if you applying for:
Clinical Diplomate _____ Research Diplomate _____ Refractive Technology Diplomate _____
1. Full Name:
________________________________________
2. Office Address:
________________________________________
________________________________________
________________________________________
Phone:(________)________________________
Fax: (________)_________________________
Email: __________________________________
3. Home Address:
________________________________________
________________________________________
________________________________________
Phone: (________)_____________________
IF YOU ARE APPLYING FOR THE CLINICAL DIPLOMATE, PLEASE INDICATE IN WHICH YEAR YOU PLAN TO TAKE THE EXAMINATIONS:
PART 2, WRITTEN _______________
PART 3, CLINICAL/SLIDE _______________
PART 4, PRACTICAL _______________
ARE YOU A FELLOW OF THE ACADEMY? _______________
DO YOU PERSONALLY KNOW TWO CURRENT DIPLOMATES WHO COULD SERVE AS "MENTORS" (Please list their names).
1. ________________________________
2. ________________________________
IF NOT, WOULD YOU LIKE THE SECTION TO ASSIGN SOMEONE? ________________
INCLUDE WITH THIS FORM
A. A current curriculum vitae which includes your educational background and a resume of your activity in the contact lens field. Include postgraduate training, teaching experience, research, publications and activities with other contact lens organizations.
B. Application fee of $100 (U.S.) payable to:
THE AMERICAN ACADEMY OF OPTOMETRY
C. A current photograph of yourself.
SEND TO
Cornea, Contact Lenses and Refractive Technologies Section Diplomate Program
American Academy of Optometry
6110 Executive BLVD, Suite 506
Rockville MD 20852 USA
(NOTE: PLEASE DO NOT SEND CASE REPORTS TO THE ACADEMY OFFICE!!)
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