<p> DEADLINE: NOVEMBER 1, 2016 THE RETINA SOCIETY </p><p>APPLICATION FOR MEMBERSHIP MEMBERSHIP CATEGORY: (check one) 2017 □ACTIVE □ CORRESPONDING □ ASSOCIATE</p><p>PLEASE SEE INSTRUCTIONS FOR SUBMITTING YOUR APPLICATION - LAST PAGE ------CANDIDATE NAME</p><p>______LAST FIRST MIDDLE Initial DEGREE (S) Male/Female</p><p>SIGNATURE ______DATE ______</p><p>Did you complete a retina fellowship more than 3 years prior to the November 1 application date? Y N If you are applying for Active Membership, are you Board Certified in Ophthalmology? Y N If you answered No to any of the above questions, you are not eligible for membership at this time. . PROFESSIONAL ADDRESS HOME ADDRESS ______TELEPHONE: Office ______Fax ______Home ______Cell Mobile ______</p><p>EMAIL: Preferred email address:______</p><p>DATE OF BIRTH ____/____/___ COUNTRY OF BIRTH ______mm/dd/yy CITIZENSHIP ______</p><p>MARITAL STATUS ______NAME OF SPOUSE ______</p><p>1 ACADEMIC TRAINING: Institution Program/Specialty Location Degree Start Complete Date Date Undergraduat e Graduate Medical School Internship Residency 1 Residency 2 Fellowship 1 Fellowship 2 Other</p><p>BOARD CERTIFICATION: Specialty Board Name Date Certified Date Last Recertified</p><p>MEDICAL LICENSURE: State/Province Country Date Issued License Number</p><p>CLINICAL TREATMENT EXPERIENCE:</p><p>Procedure Number performed during the last Calendar Year  Scleral Buckle  Vitrectomy  Pneumatic Retinopexy  Laser  PDT  Cryopexy Intravitreal Injections</p><p>2 ACADEMIC APPOINTMENTS:</p><p>Check one:  Full-time Academic  Volunteer Faculty</p><p>What is the highest academic rank you have achieved, and at what institution? Professor Associate Professor Assistant Professor Instructor Other</p><p>Current Academic Positions Institution Faculty Position Dates from/to Percent of time Name Medical School</p><p>Hospital</p><p>Hospital</p><p>Other</p><p>Are you a director of a fellowship training program? Y N If yes, please specify program:</p><p>Are you the Chief of Service for the vitreoretinal section of your department? Y N</p><p>Are you a Department of Ophthalmology Chair? Y N If yes, please indicate department, institution:</p><p>TEACHING:</p><p>3 Institution Number of hours spent Type of student in last calendar year</p><p>Didactic lectures [actual hours of lecture time, not preparation time]</p><p>Attending in clinic as supervisor/teacher</p><p>Surgical Preceptor</p><p>AAO or ASRS Courses taught [for each, specify title, year, and course director]</p><p>1.</p><p>2.</p><p>3. </p><p>RESEARCH:</p><p>4 Grant/Study Role Government Grant / Grant/Study Title Funding Start/ Institution # sites/ Type supported Study Amount Finish where #patients (VA, DOD Number Dates research NIH, NEI); performed National; Foundation; Company; or Other (give name)</p><p>R0I ☐ PI</p><p>☐ Co-PI</p><p>☐ Co- investigator</p><p>☐ Other (name role)</p><p>Other NEI/NIH/ ☐ PI National/ Government ☐ Co-PI Grant ☐ Co- (eg, K, T, U grants) investigator ☐ Other (name role)</p><p>Foundation* ☐ PI funding requiring competitive ☐ Co-PI review of a grant ☐ Co- investigator</p><p>☐ Other (name role)</p><p>Industry ☐ PI sponsored study (IST) requiring ☐ Co-PI submission of proposal ☐ Investigator </p><p>National ☐ National N/A N/A N/A Leadership in PI NIH funded ☐ Steering Multicenter Trial Committee (e.g. CATT, ☐ Data DRCR, SCORE) Safety MC</p><p>☐ Other (name)</p><p>5 National ☐ National N/A N/A N/A Leadership in PI Industry ☐ Steering Sponsored Trial Committee (eg., VIEW 1, 2) ☐ Data Safety MC</p><p>☐ Other (name) Local Site N/A N/A Investigator NEI-sponsored or similar Government Agency Multicenter Trial (eg., DRCR.net, MUST, PEDIG, ☐ PI CATT) List last 3 ☐ Co-PI trials ☐ 1. Investigator</p><p>☐ PI 2. ☐ Co-PI ☐ Investigator</p><p>3. ☐ PI ☐ Co-PI ☐ Investigator</p><p>Local Site N/A N/A Investigator Industry- sponsored, Multicenter Trial (eg., RISE/RIDE, VISTA, etc.) List last 3 trials ☐ PI 1. ☐ Co-PI ☐ Investigator 2. ☐ PI ☐ Co-PI ☐ 3. Investigator</p><p>☐ PI ☐ Co-PI ☐ Investigator</p><p>* examples include Foundation Fighting Blindness, American Diabetes Association, American Heart Association, Knights Templar Eye Foundation, March of Dimes </p><p>6 Other Research Activities: Please elaborate here. [If necessary, add an additional page and insert immediately after this page]</p><p>PUBLICATIONS:</p><p>Please fill in the table below with number of publications in each category. Only list articles in peer reviewed journals.</p><p>Number Number Number Number publications publications publications not publications primarily primarily primarily vitreo not primarily vitreoretinal vitreoretinal retinal in last 5 vitreoretinal topic in last topic more than years more than 5 5 years 5 years ago years ago</p><p>1st author or corresponding author [or lead author in writing committee]</p><p>Named co-author [or part of writing committee]. Please do not include articles in which you are listed as co- author in an appendix.</p><p>Co-author, not named in byline, but listed in appendix [e.g. site PI for a multicenter trial]</p><p>Letters to Editor, lead author</p><p>Book chapter 1st author </p><p>Book chapter co-author</p><p>Book editor</p><p>Book author</p><p>7 PRESENTATIONS AT NATIONAL AND INTERNATIONAL MEETINGS DURING LAST 5 YEARS*: In the table below please only list items where you were the presenter or first author. Meeting Number during the past 5 years</p><p>AAO ___ Papers ___ Posters</p><p>ARVO ___ Papers ___ Posters</p><p>ASRS ___ Papers ___ Posters</p><p>Retina Society ___ Papers ___ Posters</p><p>Macula Society ___ Papers ___ Posters</p><p>Other National/ ___ Papers ___ Posters International meetings [Include meeting names]</p><p>Named Lectureship [Indicate date, name of the lectureship and lecture title]</p><p>8 *Including only presentations noted in the above table, please print out a list in chronological order, most recent at top, with the following information for each paper or poster: date, meeting, title of presentation, and whether it was a paper or poster. Please convert this to a PDF file for submission, and title the file: Lastname_Firstname_2016_Presentations</p><p>PROFESSIONAL SOCIETIES:</p><p>NAME HOW LONG HAVE YOU OFFICES HELD, COMMITTEES SERVED BEEN A MEMBER?</p><p>______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>OTHER CONTRIBUTIONS WHICH SHOULD BE CONSIDERED: Please indicate any special achievements, positions, teaching, research or community service in the field of retinal diseases, or otherwise in the space below: </p><p>YOUR SPONSORS:</p><p>Recommendations will be required from two Retina Society Active Members. You should make sure that they agree to sponsor you and are aware of the application deadline. We will contact them to fill out our evaluation and recommendation form.</p><p>Sponsor 1: Name: ______</p><p>Address: ______</p><p>City: ______State: ______Zip: _____</p><p>9 Email Address: ______</p><p>Phone Number: ______</p><p>Sponsor 2: Name: ______</p><p>Address ______</p><p>City: ______State: ____ Zip: ______</p><p>Email Address: ______</p><p>Phone Number: ______</p><p>INSTRUCTIONS FOR SUBMITTING YOUR APPLICATION:</p><p>Please fill out the application form as completely as possible (do not put “please see CV” anywhere). This will be to your advantage and will assist the Credentialing Committee in properly reviewing your application.</p><p>Your application should be uploaded online at www.retinasociety.org prior to November 1, 2016. Please do not submit your application until it is complete. If there are any questions as you proceed, contact Judy Keenan at [email protected], or call her at 617- 227-8767.</p><p>Your application will consist of the following PDF files to be uploaded:</p><p>1. Upload a PDF of your CV titled “Lastname_Firstname_2016_CV” 2. Scan this completed application form, save it to PDF format titled “Lastname_Firstname_2016_Applic”and upload the PDF. 3. If presentations are listed as part of this application, upload a list of these presentations as requested in the section on Presentations in this application. The PDF should be titled“Lastname_Firstname_2016_Presentations” 4. If you have publications, please upload two additional PDF files: a. Please print a PubMed printout of your publications, and circle your name in each citation. Scan the resultant document, and save it to PDF format. Upload the PDF titled</p><p>“Lastname_Firstname-2016_ Pubmed” b. Please print out the cover page of each of your publications from the last 5 years, arrange them in order most recent on top, scan the group, and save all to one single 10 PDF document. Please upload the PDF titled “Lastname_Firstname_2016_Publications”</p><p>Please indicate the number of PDF files you are submitting in total: ______</p><p>Thank you for submitting this application and for your interest in the Retina Society.</p><p>11</p>