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To enhance oral health globally by advancing the science, practice and ethics of implantdentistry and tissue engineering.ACADEMY OF OSSEOINTEGRATIONAPPLICATION FOR FELLOWSHIPAPPLICATION INSTRUCTIONS: A minimum of fifteen (15) points total is required for the application toqualify for Fellowship. There is no cross compensation of points between sections 1-3. However, if therequired points within sections 1-3 are not met, points from section 4 can be applied to compensate for thedifference. Applicants are responsible for providing and labeling all required and supporting documents.Incomplete applications will be returned to the applicant. Please complete the following sections as instructed:APPLICANT INFORMATIONName of Applicant: Company/Institution:Mailing Address:City:Zip/Postal Code:Telephone:State/Province:Country:Fax:Email Address:1

PRE-APPLICATION REQUIREMENTSThe following prerequisites are required of applicants:1. Applicant must be a qualified DMD/DDS/PhD or equivalent, with a minimum of ten years, activelyinvolved in dentistry, in either a clinical or research setting or working in an implant-related academicposition minimum three days/week. (Excluding post-graduate training/research.)Please provide DMD/DDS/PhD or equivalent copies of certificate identifying year of graduation and aletter from your head of department confirming your contractual commitments and/or evidence of yourinvolvement in private practice.2. Applicant must be a member of Academy of Osseointegration (AO) for five (5) consecutive years.Please list the years in which you have been an Active member of the Academy of Osseointegration:___________________________________________________________________________________3. Applicant must have attended a minimum of three (3) Academy of Osseointegration Annual Meetingswithin the last seven (7) years.Please list which three (3) years you have attended the Academy of Osseointegration Annual Meetings:___________________________________________________________________________________4. Applicant is required to provide supporting testimonials from two (2) current Fellows of the Academy ofOsseointegration. (Please refer the most recent AO Membership Directory for a listing of Fellows of theAcademy.)Please list each Fellows’ name:______________________________________________________________________2

REQUIREMENTSSECTION 1 – SERVICESix (6) points are required from Section 1.Please list the roles and years of service you have provided to the Academy of Osseointegration.Committee Member – (1 point per completed year)Committee NameYearPoint(s)Committee Chair – (1.5 points per completed year)Committee NameYearPoint(s)AO/Osseointegration Foundation (OF) Board of Directors – (2 points per completed year)Board NameYearPoint(s)AO/OF Executive Committee/Officer Positions – (3 points per completed year)Board NameYearPoint(s)TOTAL POINTS FROMSECTION 13

SECTION 2 – STUDY & PUBLICATIONSFive (5) points are required from Section 2.Please indicate and label the documentation and/or publications to be submitted with the application.Submission of seven consecutive years of implant related ADA-CERP verification ofparticipation documents (or local equivalent evidence of further continuingeducation). Requirement is a minimum of 210 hours (not including company-specificcourses).(4 points)Point(s)Evidence of having obtained a higher degree in a University-based Implant Program(Masters or equivalent only) or completion of residency program in mono-specialty.(3 points)Point(s)Authored or co-authored, a published article on implant dentistry or related area ofresearch in IJOMI.(2 points per article)Point(s)If you are submitting more than one article, please list the quantity here: __________Authored or co-authored, a published article on implant dentistry or related area ofresearch in any other peer-review journal.(1 point per article)Point(s)If you are submitting more than one article, please list the quantity here: __________Authored or co-authored, a published textbook chapter on implant dentistry or relatedarea of research.(1 point per chapter – maximum of 2 chapters)Point(s)If you are submitting more than one chapter, please list the quantity here: _________Authored or co-authored, a published textbook in implant dentistry or related area ofresearch.(3 points per book)Point(s)If you are submitting more than one textbook, please list the quantity here: ________TOTAL POINTS FROMSECTION 24

SECTION 3 – PRESENTATIONSFour (4) points are required from Section 3.Please indicate the presentation type.Academy of Osseointegration Annual Meeting Poster Presentation(1 point per meeting)Presentation NameYear PresentedPoint(s)Academy of Osseointegration Annual Meeting Abstract Presentation (Scientific or Clinical)(1 point per meeting)Presentation NameYear PresentedPoint(s)Academy of Osseointegration Lunch and Learn Presentation(1 point per meeting)Presentation NameYear PresentedPoint(s)Academy of Osseointegration Round Table Clinic Presentation(1 point per meeting)Presentation NameYear PresentedPoint(s)5

SECTION 3 – PRESENTATIONS (CONTINUED)Academy of Osseointegration Limited Attendance Lecture Presentation(2 points per meeting)Presentation NameYear PresentedPoint(s)Academy of Osseointegration Annual Meeting Moderator(1 point per meeting)Presentation NameYear PresentedPoint(s)Academy of Osseointegration Plenary Session Presentation(3 points per meeting)Presentation NameYear PresentedPoint(s)Plenary program presentation on implant related subject at any of the conference sponsored by thefollowing: AAOMS, AAP, ACP, ADA, AGD, EAO – (2 points per meeting)Presentation NameYear PresentedSponsoringOrganizationPoint(s)TOTAL POINTS FROMSECTION 36

SECTION 4 – OUTREACH & PHILANTHROPYPoints are not mandatory from this section.Please indicate the amount donated to the Osseointegration Foundation to date or if you have completedOutreach activity. (Previous donations in the below amounts can be applied to Section 4.)Osseointegration Foundation Donations of $10,000 or above – (3 points)Osseointegration Foundation Donations between $5,000 -$9,999 – (2 points)Osseointegration Foundation Donations between $2,000 - $4,999 – (1 point)Any outreach activity which fulfills the Academy of Osseointegration’s mission statement* – (1 point)*Please provide appropriate evidence and testimonials of support. Qualifying outreach activities will bedetermined by the Membership Committee.TOTAL POINTS FROMSECTION 4POINT TOTALTOTAL POINTS FROM SECTION 1TOTAL POINTS FROM SECTION 2TOTAL POINTS FROM SECTION 3TOTAL POINTS FROM SECTION 4GRAND TOTALSUPPORTING DOCUMENTSPlease provide copies of certificates only, as these are required for verification. You should include yourcertificate of dental graduation, or higher educational degree, all CERP certificates (or local equivalent evidenceof further continuing education), and certificates of attendance to Academy of Osseointegration and othermeetings. In addition, any evidence to support your application, such as copies of conference programs in whichyou have lectured or article reprints, etc., is advised to help speed up the process.DISCRETION OF THE BOARDPlease be advised that while every effort has been made within the context of this point system to be inclusivefor a variety of activities, the Academy of Osseointegration Board and Membership Committee reserve the rightto include additional activities not listed or exclude activities deemed inappropriate. Any decision to exclude anactivity that might result in failure to obtain Fellowship will be explained to the applicant in full.7

Return the completed application and all supporting documents to:Academy of OsseointegrationAttn: Membership Department85 West Algonquin Road, Suite 550Arlington Heights, IL 60005For questions or more information, please contact Membership Services, at847-439-1919 or Fax: (847) 439-1569 or (800) 416-7736Website: www.osseo.org8