ASSOCIATE MEMBERSHIP ORTHOPAEDIC

We invite you to Apply for ASSOCIATE MEMBERSHIP ORTHOPAEDIC Application and Instruction Booklet Class of 2018 FINAL Application Deadline: April 1, 2017 ** All documents must be in the AAOS office by this date **

Dear Doctor, The American Academy of Orthopaedic Surgeons invites you to apply for Associate Membership Orthopaedic in the Class of 2018. Please read the following information and the Instruction Booklet attached to find out more regarding AAOS membership. This membership category is intended for Orthopaedic Surgeons who are not eligible to sit for the American Board of Orthopaedic Surgery examination but are eligible to apply for the Associate Membership Orthopaedic membership category in the AAOS. AAOS Membership supports the Academy s efforts in advocacy on many critical Health Policy issues facing all of orthopaedics. You will enjoy programming, services, peer recognition and networking opportunities with over 35,000 orthopaedic surgeons from around the world. Your valuable membership benefits include: Free advanced registration for the AAOS Annual Meeting A complimentary subscription to o The Journal of the American Academy of Orthopaedic Surgeons o AAOS NOW Complimentary access to Orthopaedic Knowledge Online Access to AAOS OrthoPortal, search and browse all online publications and educational resources from AAOS www.orthoportal.org Preferred rates for all products and courses All Academy members are listed in the Public Membership Directory, which is a service to the public allowing them to search for an orthopaedic surgeon in their preferred location. It allows you to customize your listing and create your personal and/or practice Web site. Please read the enclosed instructions carefully to determine if you are eligible to apply for this category of membership and be sure to submit the completed application, including your Sponsor Forms and other required documents, before the deadline of April 1, 2017. Your application will be acted upon by the Board of Directors in the Fall of 2017. The AAOS Membership Department is always available to respond to any questions you might have. Please do not hesitate to contact us at (800) 346-2267 or by email at member@aaos.org. We look forward to receiving your application. Heidi Schmalz Senior Manager Member and Customer Relations

Benefits of ASSOCIATE MEMBERSHIP ORTHOPAEDIC Membership in the American Academy of Orthopaedic Surgeons is now more important than ever. Your dues support vital AAOS activities, returning your investment through benefits that assist you in managing your practice, supporting your continuing medical education, improving your practice environment through advocacy and legislative efforts, and educating your patients. The AAOS is all about YOU. Your valuable AAOS benefits include: Complimentary Advanced Registration for the AAOS Annual Meeting. This is the premier annual gathering of orthopaedic surgeons from around the world with scientific papers, Instructional Courses, Surgical Skills Courses, Symposia, technical and scientific exhibits, and the unique opportunity to meet informally with leading orthopaedic surgeons from around the world. Complimentary Subscription to the Journal of the American Academy of Orthopaedic Surgeons. Outstanding, peer-reviewed articles have made JAAOS the most widely read orthopaedic journal in the U.S. JAAOS is the official clinical journal of the AAOS. It is published 12 times a year and is also available through the AAOS Website where abstracts and the full text of all articles are available to you. Complimentary Subscription to AAOSw. The monthly AAOS w, the official member newsmagazine of the AAOS, presents timely news and in-depth reviews of orthopaedic practice and risk management, socioeconomic trends, regulatory issues, clinical and subspecialty topics, continuing medical education, technology updates, AAOS activities and other relevant information of interest to AAOS fellows. Articles are archived online on the AAOS Web site. Complimentary Access to Orthopaedic Knowledge Online. OKO puts you in touch with current, reliable peer-reviewed information on the Internet. Watch nationally recognized surgeons demonstrate their techniques with narrated step-by-step videos. Read selected articles that expand on the issues presented. tice of and Preferred Rates for AAOS Courses. Premier educational events, held throughout the country and at the Orthopaedic Learning Center in Rosemont, IL, bring together internationally recognized experts with a high faculty/participant ratio, offering Category 1 CME credit to orthopaedic surgeons in every subspecialty. In addition, several short courses are available to members on the AAOS Website. Complimentary AAOS Job Placement Service for Position Seekers. This is an online and print job database designed to help you find the right position or fill a vacancy in your practice. The search for a position is free to members and the cost to list a vacancy is nominal. In addition, your AAOS membership provides many other educational resources, which include textbooks, written and electronic self-assessment examinations, and a wide variety of patient education materials, both in print and through the website. As a member of the AAOS, you support the efforts of the AAOS in advocacy on several critical health policy issues facing orthopaedic surgeons and your patients. You will also enjoy peer recognition and networking opportunities with over 30,000 orthopaedic surgeons.

Applicants for Associate Membership-Orthopaedic Class of 2018 IMPORTANT INFORMATION DEADLINE DATE: April 1, 2017 Your application must be received in the AAOS office by the deadline to consideration in the Class of 2018 Applications received after the deadline of March 1st, will be processed with the Class of Class of 2019. Your member status does not change upon application submission. Please refer to the Application Processing Calendar for details. The Board of Directors will act upon applications at its meeting in the Fall of 2017. Members will be notified via US mail to the Primary Address on file. If accepted, induction into AAOS Membership will take place during the 2018 AAOS Annual Meeting on March 6-10, 2018 in New Orleans, LA. BASIC REQUIREMENTS FOR ASSOCIATE MEMBERSHIP ORTHOPAEDIC: The candidate for this category of membership must be ineligible to be considered for certification by the American Board of Orthopaedic Surgery because of the location of their training or other specific reasons. The candidate must submit a letter of explanation with the application and the Membership Committee will make the final determination regarding eligibility when the application is considered. Exclusive practice of orthopaedic surgery in the United States (not including fellowship training) for at least 36 months immediately prior to induction, or practice start date prior to April1, 2015. Maintenance of a full, unrestricted and unlimited license to practice medicine or full-time service in the federal government. Citizen of or practice in the United States. Compliance with the AAOS Standards of Professionalism, and maintenance of a good reputation and standing within the community. APPLICATION REQUIREMENTS: There is no application fee. However, a Class of 2018 Initiation Fee is payable upon election to Membership. Annual membership dues are billed each spring. By April 1, 2017, EACH APPLICANT MUST: (checklist for your convenience) PERSONALLY READ, COMPLETE, AND SIGN THE APPLICATION FORM. The applicant is solely responsible for the content, supporting documents, and accuracy of the application. THIS RESPONSIBILITY CANNOT BE DELEGATED. Attach supporting documents and a current wallet size photograph to your application. (Your responses to the application questions determine which supporting documents are required.) Ensure that every period of time since medical school graduation is accounted for, including residencies, fellowships and military service, as well as all locations of practice. Name two AAOS Active Fellows who are familiar with your practice as SPONSORS. It is strongly advised that they be in your community. Ensure that both sponsors meet the requirements as listed in the "Sponsor Requirements" details (see below). Both sponsor recommendations must be received in our office, before March 1, 2017. The name of each applicant is circulated to the AAOS membership for comment. Your sponsors may be contacted by the AAOS if the Membership Committee desires further information. The AAOS is not responsible for contacting your sponsors to request sponsor documentation on your behalf. Submit a signed hard copy of your application. (see page 1 of the application for application return address) Incomplete applications or applications received after the deadline will not be processed. SPONSOR REQUIREMENTS: The AAOS bylaws require each applicant to have at least two sponsors. Sponsors must be Active or Emeritus AAOS Fellows. Both sponsors must be knowledgeable about the applicant s practice. Written sponsorship letters or completed AAOS Sponsor forms will be accepted and are required. Your application will not be considered complete, without 2 written recommendations.

RESPONSIBILITY TO PROVIDE INFORMATION: It is the responsibility of the applicant to provide the information on which the Membership Committee can base its evaluations of the qualifications of the applicant. The Membership Committee may request an applicant to provide and/or to authorize others to provide information, medical records and documents that they believe to be relevant to his or her qualifications. The applicant's responsibility to provide information extends to information that is requested from other persons. If the Membership Committee does not receive requested information that it believes to be relevant to the qualifications of an applicant from the applicant, a sponsor, the chair of an orthopaedic residency program, a hospital representative, or another source, the AAOS will defer making a recommendation as to the admission of the applicant until the information is received. PROCEDURE FOR THE PROCESSING OF APPLICATIONS The Board of Directors will consider applications at its meeting in the Fall of 2017 The AAOS Bylaws outline and the Board of Directors has adopted procedures for the uniform processing of applications. It is essential that they be observed impartially and explicitly. All applications are reviewed in the following manner: After April 1, 2017, the AAOS reviews each application for completeness and prepares the application for the Membership Committee. Incomplete applications will not be considered. A list of applicants is sent to the AAOS Membership for review and comment. All comments received are included in the application file and are considered confidential. The applications are then sent to the Chair of the Membership Committee who may request additional information from you or your sponsors. The National Membership Committee meets in the summer to review applications and comments received. They develop recommendations regarding each applicant. The Board of Directors, during its fall meeting, considers the applications for Membership presented by the National Membership Committee. After review of all information, one of three actions will be taken: 1. Approve 2. Defer 3. Reject Deferred applicants may be requested to provide additional information or undergo a practice audit to enable the Membership Committee to make a recommendation to the Board of Directors regarding the applicant. Rejected applicants may reapply for Membership or request an Admissions Hearing, as provided in the AAOS Bylaws and the Admissions Hearing Procedures adopted by the Board of Directors. The decision of the Board of Directors will be considered final for all applicants who are approved. The decision of the Board of Directors will not be considered final for an applicant who has been deferred. A final AAOS action is not taken until the applicant is either accepted or rejected. The decision of the Board of Directors will be considered final for a rejected applicant if, after thirty (30) days of receiving the notice of the rejection, the applicant has not withdrawn his or her application or has requested an Admissions Hearing according to the procedures established in the AAOS Bylaws. In addition, if the rejected applicant, after receiving the notice of rejection, requests an Admissions Hearing, the decision of the Board of Directors will be considered final only when the Board of Directors has taken action on the recommendations of the Admissions Hearing Committee. OTHER IMPORTANT PROVISIONS Health Care Quality Improvement Act; National Practitioner Data Bank Under the Health Care Quality Improvement Act of 1986, the AAOS is considered a health care entity that conducts a formal peer review process for the purpose of furthering quality health care. As such, the AAOS and any person who provides it with information regarding an orthopaedic surgeon's activities (which affect the health or welfare of a patient or patients) is immune from liability in private damage actions under most federal or state laws. In addition, under the Act, the AAOS is obliged to report to the Illinois Department of Professional Regulation (National Practitioner Data Bank) any final decisions to withhold Membership that are based on patient care-related grounds. Confidentiality In accordance with the AAOS Bylaws, every aspect of the application and election process concerning a particular applicant is privileged and confidential. material gathered during the course of the application review will be made available to any person or individual, including the applicant, except where required under the AAOS hearing procedures or by operation of law. n-discrimination Consistent with federal and Illinois law, the AAOS does not discriminate on the basis of race, color, gender, sexual orientation, religion or national origin, or on any basis that would constitute illegal discrimination.

Illinois Law The privilege of being considered for election as an AAOS Member is governed by the law of the State of Illinois, where the AAOS offices are located. Illinois law provides that an applicant may not seek judicial review of an adverse decision on his or her application except where membership has been held by a court of law to be an economic necessity. The law of the State of Illinois shall govern every aspect of an application for Membership and the election process. Application Processing Calendar Class of 2018 Practice History Required to apply (see inst ructions for complete list of basic requirements) April 1, 2017 Exclusive practice of orthopaedic surgery in the U.S. since March 1, 2015 or prior Class of 2018 application deadline Submissions received after the deadline will not be considered February - September 2017 Late September 2017 application review by the Membership Committee Board of Directors act on Class of 2018 applications Applicants are notified of member status in writing via U.S. mail IF ACCEPTED October 2017 March 6-10, 2018 * Your AAOS member category officially changes to Associate Member Orthopaedic * You will receive your official AAOS Member Card in the mail * Mandatory Initiation Fee billed for the period of vember 2017- March 2018. Annual Meeting in New Orleans, LA and Induction of the Class of 2018 April of 2018 Your first dues as Associate Member Orthopaedic are billed for the 2018-19 dues year (800) 346-AAOS Fax (847) 268-9558 E-mail member@aaos.org www.aaos.org

* DEADLINE: APRIL 1, 2017 * PLEASE READ INSTRUCTIONS BEFORE COMPLETING * Ap p l i c a t i o n s n o t r e c e i v e d b y t h e d e a d l i n e w i l l b e p r o c e s s e d w i t h t h e C l a s s o f 2 0 1 9 Ap plication for ASSOCIATE MEMBER - ORTHOPAEDIC CLASS OF 2018 A p p l i c a t i o n r e t u r n a d d r e s s : AAO S M e m b e r s h i p C o m m i t t e e 9 4 0 0 W e s t H i g g i n s R o a d, R o s e m o n t, I L 6 0 0 1 8 T o l l F r e e : ( 8 0 0 ) 3 4 6 - A A O S F a x : ( 8 4 7 ) 2 6 8-9 5 5 8 TYPE OR PRINT EXACTLY AS YOU DESIRE YOUR NAME TO BE CARRIED IN AAOS RECORDS (REQUIRED) Please Affix Photo Here (tape only) Page 1 of 4 ** no staples or paper clips please ** Applications without photo will not be processed APPLICANT: FEMALE MALE Last Name First Name Middle Name or Initial XXX XX Date of Birth SS # (last 4 # s) Personal E-Mail (for application status correspondence) YOUR AAOS ID# BIRTHPLACE: City & State / Country Country of CITIZENSHIP Please list both your OFFICE and HOME addresses and mark ONE as the PRIMARY MAILING ADDRESS for AAOS Correspondence OFFICE ADDRESS: Practice, Office or Hospital Name : Dept., Suite, Bldg., Mail Stop, etc. : Street Address PRIMARY address City: State or Province: Zip Code: Telephone #: Fax #: HOME ADDRESS: Office Email: PRIMARY address Street Address City: NAME AND ADDRESS OF (2) SPONSORS: State or Province: Zip Code: (Sponsors must be AAOS ACTIVE FELLOWS in your community) 1. 2. Practice Name: Street Address Practice Name: Street Address City & State Zip: City & State Zip: Telephone # Telephone # ORTHOPAEDIC TRAINING PROGRAM CHAIR: Please list the details applicable while you were enrolled. Submit a separate page if needed 1. RESIDENCY PROGRAM CHAIR at time of your Residency 2. FELLOWSHIP PROGRAM CHAIR at time of your Fellowship Chair: Institution Name: Street Address: Chair: Institution Name: Street Address: City & State: Zip: City & State: Zip: Telephone #: Telephone #:

Name of applicant: 1. a). Do you hold a certification in Orthopaedic Surgery? YES NO b). Name of Board Location and Date Page 2 of 4 2. Date you began your orthopaedic practice 3. Date you began orthopaedic practice in your present location 4. Do you limit your practice exclusively to orthopaedic surgery? YES NO * If NO please explain below 5. Medical Education: Degree (s) Institution Location Year(s) Enrolled From To 6. Orthopaedic Residency Year(s) Completed: Program Name(s) or Institution(s) Institution and Major(s) or Field(s) of Study Year(s) Enrolled From To 7. Post Graduate Fellowship(s): Topic(s) / Sub-Specialty Length (Months) Year Completed Program Name(s) or Institution(s) 8. List Hospital(s) in which you currently have ACTIVE HOSPITAL PRIVILEGES: Hospital Name City, State Dept. Restrictions YES YES NO NO YES NO YES NO 9. TEACHING AFFILIATIONS: If yes, please provide full details on a separate sheet of paper. 10. LICENSED to practice in the following states: (specify license numbers and valid dates for CURRENT LICENSES) State License # Issue Expire Month/ Year Month/ Year State License # Issue Expire Month/ Year Month/ Year

Name of applicant: Page 3 of 4 11. PRACTICE HISTORY including years in each location: (All time since completion of training must accounted for) Practice Name (start with current practice) Address Year(s) Employed From To 12. Practice Setting: Solo Practice Orthopaedic Group Multispecialty Group Full-Time employee of Medical School or University Other 13. Special Orthopaedic Interest(s) 14. Military Service: From To General Medical Orthopaedic 15. Additional Data a) Medical Society Memberships: (After the hyphen, list any office or committee appointment you hold or have held) b) Contributions to Medical Literature: (Append sheet if additional space is required) c) Other Scientific Contributions (Append sheet if additional space is required) Your signature must appear on the last page.

Name of applicant: Page 4 of 4 16. Has your license to practice medicine in any jurisdiction ever been limited, suspended, or revoked? Is your license the subject of a pending action or investigation? 17. Have your privileges at any hospital ever been denied, suspended, restricted, revoked, deferred, or reviewed pursuant to disciplinary action or not renewed? 18. Have you ever withdrawn your application for privileges at a hospital? 19. Has your narcotic registration ever been suspended or revoked? 20. Have you ever been counseled, censured, or subject to disciplinary action in any medical organization, educational institution, or practice facility? 21. Have you ever had an article or publication retracted? 22. Have you ever been convicted of a felony? 23. Are you currently involved in any litigation involving patient care? 24. Have you ever been involved in a suit in which there was an adverse settlement or judgment? 25. Have you ever been reported to the National Practitioner Data Bank? If you answered yes to question #25, please attach the National Practitioner Data Bank report(s) to your application. NOTE: If you have answered YES to any of the questions listed above (16 to 25), in your words, please provide FULL DETAILS on a separate sheet of paper. Please include your name on each page and attach the document(s) to your application. Applications without proper documentation will not be processed. I agree to comply with the Bylaws of the AAOS, The AAOS Standards of Professionalism and with all the rules and regulations adopted pursuant to them. I understand that these bylaws and the AAOS Standards of Professionalism are available on the AAOS website, www.aaos.org. I further agree that, in return for the AAOS treating the entire contents of this application as confidential, privileged information, the AAOS is authorized to make whatever inquiries and investigations it deems appropriate to verify my credentials, professional standing and moral or ethical character. In addition, I agree that I will not cause or attempt to cause any disclosure, public or private, of the contents of my application or of any proceedings of any AAOS Committee conducted in connection with my application except as provided in the AAOS Bylaws. I affirm and state that the information furnished in this application is true. I recognize that the AAOS does not discriminate on the basis of race, color, gender, sexual orientation, religion, or national origin, or on any basis that would constitute illegal discrimination. I am also aware that the application is governed by the laws of the State of Illinois, where the offices of the AAOS are located. Should any dispute arise from this application process, I agree to be bound by the laws of the State of Illinois. P L E A S E R E V I E W Y O U R A P P L I C A T I O N F O R A C C U R A C Y and A F F I X P H O T O TO P A G E 1. S I G N A N D S U B M I T T H E A P P L I C A T I O N H A R D C O P Y V I A M A I L. A L S O, IF A P P L I C A B L E, A T T A C H ANY S U P P O R T I N G D O C U M E N T S. E L E C T R O N I C S I G N A T U R E S N O T A C C E P T E D. Signature Date The AAOS office must receive your application on or before the deadline date for consideration.

AAOS CLA SS OF 2018 SPONSOR FORM AAOS Member Services Dept., 9400 West Higgins Road, Rosemont, IL 60018 Toll Free: (800) 346-AAOS Fax: (847) 268-9558 Name of APPLICANT Page 1 of 2 (Please type or print) Address Address City State Zip Code PLEASE COMPLETE PROMPTLY AND RETURN THIS FORM TO THE AAOS NO LATER THAN: April 1, 2017 SPONSOR Name: (Please print) AAOS ID#: 1. How long have you known this applicant? # years # months 2. Is the applicant associated with you in practice? # years # months 3. Is the applicant s practice limited to Orthopaedic Surgery? If NOT please comment: 4. Is the applicant well regarded by the physicians in the community? 5. What is your opinion regarding the applicant s reputation, standing within the community, and ethical behavior? Excellent Good Fair Poor Unknown 6. What is your opinion regarding the applicant s standard of patient care? Excellent Good Fair Poor Unknown 7. Is the applicant well regarded by the hospital staff? DO NOT SEND THE FORM BY BOTH MAIL AND FAX

AAOS SPONSOR FORM CLASS OF 2018 Name of APPLICANT Page 2 of 2 8. Have you assisted or observed the applicant in the operating room? 9. What is your opinion regarding the applicant s surgical judgment and skill? Excellent Good Fair Poor Unknown 10. Do you recommend the applicant to the Academy for membership? 11. Please comment on any other specific areas which will be helpful to the Membership Committee in its review of this applicant. (Please use a separate sheet of paper if needed.) 12. Are you an ACTIVE FELLOW of the American Academy of Orthopaedic Surgeons? IMPORTANT Name (PRINT or TYPE) P l e a s e f a x the f r o nt and b a ck si d e s o f thi s f o r m to ( 847) 268-9558 b y April 1, 2017 OR mail to: Membership Committee American Academy of Orthopaedic Surgeons 9500 W. Higgins Rd Rosemont, IL 60018 Signature Date Practice, Hospital or Office Name Dept, Suite, Bldg, Mail Stop, etc. Street Address City State Zip Office Telephone number (include area code) DO NOT SEND THE FORM BY BOTH MAIL AND FAX

AAOS CLAS S OF 2018 SPONSOR FORM AAOS Member Services Dept., 9400 West Higgins Road, Rosemont, IL 60018 Toll Free: (800) 346-AAOS Fax: (847) 268-9558 Name of APPLICANT Page 1 of 2 ( P l e a s e t y p e o r p r i n t ) Address A d d r e s s C i t y S t a t e Z i p C o d e PLEASE COMPLETE PROMPTLY AND RETURN THIS FORM TO THE AAOS NO LATER THAN: April 1, 2017 SPONSOR Name: AAOS ID#: (Please print) 1. How long have you known this applicant? # years # months 2. Is the applicant associated with you in practice? # years # months 3. Is the applicant s practice limited to Orthopaedic Surgery? If NOT please comment: 4. Is the applicant well regarded by the physicians in the community? 5. What is your opinion regarding the applicant s reputation, standing within the community, and ethical behavior? Excellent Good Fair Poor Unknown 6. What is your opinion regarding the applicant s standard of patient care? Excellent Good Fair Poor Unknown 7. Is the applicant well regarded by the hospital staff? DO NOT SEND THE FORM BY BOTH MAIL AND FAX

AAOS SPONSOR FORM CLASS OF 2018 Name of APPLICANT Page 2 of 2 8. Have you assisted or observed the applicant in the operating room? 9. What is your opinion regarding the applicant s surgical judgment and skill? Excellent Good Fair Poor Unknown 10. Do you recommend the applicant to the Academy for membership? 11. Please comment on any other specific areas which will be helpful to the Membership Committee in its review of this applicant. (Please use a separate sheet of paper if needed.) 12. Are you an ACTIVE FELLOW of the American Academy of Orthopaedic Surgeons? I M P O R T A N T Name (PRINT or TYPE) P l e a s e f a x t h e f r o n t a n d b a c k s i d e s o f t h i s f o r m t o ( 8 4 7 ) 2 6 8-9558 b y April 1, 2017 OR mail to: Membership Committee American Academy of Orthopaedic Surgeons 9400 W. Higgins Road Rosemont, IL 60018 Signature Date Practice, Hospital or Office Name Dept, Suite, Bldg, Mail Stop, etc. Street Address City State Zip Office Telephone number (include area code) DO NOT SEND THE FORM BY BOTH MAIL AND FAX