Fields marked in blue are required for all applicants.
Fields marked in purple are only required for certain applicants - see notes below.

First Name:
Middle Initial:
Last Name:
Title/Degree:	MD DO Other:
Date of Birth (MM/DD/YYYY)	/ /
Mailing Address and Personal Contact Information
Street or PO Box:
City:
State:
ZIP:
Home/Cell Phone:
Personal Email:
Office/Billing Address and Contact Information
Practice Name:
Street or PO Box:
City:
State:
ZIP:
Office Phone:
Office Email:
Office Assistant Name:
Asst. Phone:
Asst. Email:
Preferred Method(s) of Contact:	Office Phone Home/Cell Phone Office Email Personal Email Mailing Address Office/Billing Address Other:
Education and Licensure
Medical School:
Year of Graduation:
Internship Location:
End Date:
Residency Location:
End Date:
Fellowship Location:
End Date:
Subspecialty(s):
Practice Setting:	Solo Private Group Private Multi-Specialty Private Academic Military
Hospital Privileges:
Licensure State:
Year Issued:
Expiration Date:
Has license to practice medicine ever been suspended or revoked?	No Yes
Certification by American Board of Orthopaedic Surgeons:	No Yes
Year:
Board Eligible:	No Yes Already certified
If yes, when will you take the examination? (year)
Part I:
Part II:

Membership Categories (Please check appropriate category)

$300 Active - Active membership is limited to diplomates of the Amercian Board of Orthopaedic Surgery. Active members may attend all meetings of members and Executive Sessions, participate in all proceedings conducted by the Association, serve on the Board of Directors and the Nominating Committee, and be elected to any office within the Association. Active members may vote on any issue to be decided by the membership. $300 Associate - Individuals who have completed a bona fide orthopaedic residency program and are practicing orthopaedic surgery, but have not ever become diplomates of the American Board of Orthopaedic Surgery, are eligible for Associate membership. Associate members have all the rights of active members, except that of voting, serving on the Board of Directors or the Nominating Committee, and holding office. $150 Affiliate - Non-Physician - by invitation and have the following qualifications: Graduate from a recognized and accredited professional school with certification as Physician Assistant or Nurse Practitioner, Hold current licensure in their specialty interest in the State of Louisiana, Practice profile is exclusively (100%) musculoskeletal, OR Be employed as the manager of an orthopaedic practice of an LOA Active member and have current membership in the American Academy of Orthopaedic Executives (AAOE) Application for membership must be sponsored by a physician member of the LOA. Affiliate members have all the rights of active members, except that of voting, serving on the Board of Directors or Nominating Committee, and holding office. Required Sponsor Name: $300 Affiliate - Physician - by invitation and have the following qualifications: Graduate from a recognized and accredited professional school with certification as Doctor of Medicine or Doctor of Osteopathy, Hold current licensure in their specialty interest in the State of Louisiana, Practice profile is exclusively (100%) musculoskeletal, OR Be employed as the manager of an orthopaedic practice of an LOA Active member and have current membership in the American Academy of Orthopaedic Executives (AAOE) Application for membership must be sponsored by a physician member of the LOA. Affiliate members have all the rights of active members, except that of voting, serving on the Board of Directors or Nominating Committee, and holding office. Required Sponsor Name: FREE Candidate - Medical doctors who are actively participating in an accredited orthopaedic residency or fellowship program shall be eligible for Candidate membership. Candidate members have all the rights of active members, except that of voting, serving on the Board of Directors or Nominating Committee, and holding office. Program Director's Name:

Payment Information (Applicants for Candidate membership DO NOT need to complete this section.)

Card Type: MasterCard Visa Discover Name on Card: Card Number: Card Address: Card Zip Code: Expiration Date: Month 01 02 03 04 05 06 07 08 09 10 11 12 / Year 20182019202020212022202320242025202620272028 CVV Security Code:

By clicking "Submit", I certify that I meet the above criteria established for the category of membership for which I am applying and authorize the LOA to verify the accuracy of information provided.

The Louisiana Orthopaedic Association is an Internal Revenue Code Section 501(c)3 organization. Membership dues may be deducted as a business expense to the extent allowed by law. Charitable donations may be tax deductible as allowed by law. Tax ID# 72-0888676