Online Membership Application – The Cleveland Ophthalmological Society

General Information

To become a member of the Cleveland Ophthalmological Society, please submit the below application for review.

After submitting your membership application, you will be contacted by the COS office via email with further information.

*Applications must be received no later than 2 weeks prior to the first meeting that you plan to attend.

Thank you for your interest in joining the Cleveland Ophthalmological Society.

Required fields are marked with *

First Name*

Middle Initial

Last Name*

Degree*

Current Practice / Affiliation*

Sub-Specialty*

Office Address*

Suite

City*

State*

ZIP Code*

Office Phone Number*

Home Address*

City*

State*

ZIP Code*

Cell Phone Number*

Email Address For All COS Communication*

Enter a valid email

Assistant First Name

Assistant Last Name

Assistant Phone Number

Medical School*

Graduated:*

Enter the year of graduation

Internship

Year

Residency

Year

Fellowship

Year

Certified By the American Board of Ophthalmology*YesNo

Year/Anticipated Year

Practice Limited To