PHILADELPHIA ORTHOPAEDIC SOCIETY

Date:______________

Name_________________________________________________________

Office Address__________________________________________________

City, State, ZIP: _________________________________________________

Phone :__________________________ Fax:___________________________

Email:_______________________

Required Endorsements:

TO THE APPLICANT - (Please have your sponsors endorse your application here)

I wholeheartedly endorse
(applicant's name)_______________________________________________________
for membership in The Philadelphia Orthopaedic Society.

Endorsers: (1)____________________________________________________________________

(P.O.S. member, please sign and print your name on this line.)

(2)______________________________________________________________________________

(P.O.S. member, please sign and print your name on this line.)

After you have completed this form, and have secured the two signatures of your endorsers,
please forward to:

Philadelphia Orthopaedic Society
684 Ridge Road
Spring City, PA 19475
Attn:Eleanor A. Slanga
Executive Director

Tel:610-469-9241
Fax: 610-469-0204

Please remember to:

1. Have your endorsers sign

2. Include a copy of your current Curriculum Vitae

3. Please include your dues payment for $150
and make check payable to: Philadelphia Orthopaedic Society.