LAEPS Membership Application

Personal Information

First Name*

Last Name*

Primary Office / Practice / Institution Name *

Address*

Address2

City*

State*

Zip*

This is my preferred address for mailing.

Email*

Business Phone*

Mobile number (for internal use only)

Practice Administrator*

Practice Administrator Email*

Business Information

Specialty within Ophthalmology:

Other MDs in practice

Business Website

Medical Education

Medical School*

Completion Date*

Residencies / Fellowships (Program)

Completion Date

Membership Type and Dues

Membership Dues Amount and Type*

Active Member Dues $600

2nd Year New Physician $300

1st Year New Physician No Charge

Ophthalmology Residents No Charge

Ophthalmology Fellows No Charge

Retired No Charge

Donation Amount: (WITHOUT dollar sign)

By submitting this form, you certify that:
1. The above information is true.
2. You are a duly licensed physician practicing Opthalmology in Louisiana.

I hereby apply for membership in the LAEPS and agree to abide by its Constitution and Bylaws.*

I Agree

Comment

Payment Information

If you have selected a Free Membership Type and the Total Amount due is $0, then you can ignore the payment method selection below.

Total Amount

Payment method *

Credit or Debit Card
Pay by check.
Please mail to:
LAEPS, P.O. Box 80053, Baton Rouge, LA 70898-0053

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Type*

Card Holder Name*

LAEPS Membership Application

Personal Information

Business Information

Medical Education

Membership Type and Dues

Payment Information

Membership

Contact Info

Louisiana Academy of Eye Physicians and Surgeons

Membership Dues

Member Login