OMS Training Form - American Association of Oral and Maxillofacial ...

AMERICAN ASSOCIATION OF ORAL AND MAXILLOFACIAL SURGEONSCONFIDENTIALCERTIFICATION OF COMPLETION OF ORAL AND MAXILLOFACIAL SURGERYTRAINING AND EVALUATION OF APPLICATION FOR MEMBERSHIP(PLEASE PRINT OR TYPE)Name of Candidate for AAOMS MembershipDegree (s)PRIMARY OFFICE ADDRESS Suite Number City State Zip CodeTelephone Number Fax Number Primary Email AddressHOME ADDRESS Apartment Number City State Zip CodeTelephone Number Fax Number Home Email AddressTO BE COMPLETED BY CHIEF OF TRAINING PROGRAM:This is to certify that the above-named candidate for membership in the American Association of Oral and MaxillofacialSurgeons has successfully completed the oral and maxillofacial surgery training program at our institution.Name of Training Program:Address:Completion Date:In order to evaluate the candidate, the Committee on Membership requests your appraisal of his/her qualifications. I haveknown the candidate for years.-over-

Please comment directly on each of the items below:CHARACTER: Morals, trustworthiness, idealsCOMPETENCE: Professional capacity, education, fitnessETHICS: Relations with Medical-Dental colleagues, publicJUDGEMENT: Tact, diplomacy, decisivenessSTABILITY: Self-control, tolerance, social aptitudeADDITIONAL COMMENTS:Chief of Training ProgramAddressCity State Zip CodeMAIL COMPLETED FORM TO:AAOMSMEMBERSHIP SERVICES9700 W. BRYN MAWR AVE.ROSEMONT, IL 60018-5701SignatureDate