Home
Membership
Join LAEPS
Membership Applications
Online Application
Membership Services
Upcoming Events & Education Meetings
Renew Membership
Eye Health
What is an Ophthalmologist?
Eye Smart Monthly Update
EyeCare America
Advocacy
LA Legislative Session
Legislation Tracker
Capitol Contact Info
Find Your Legislators
Quick Links & Resources
About Us
Our Mission and Goal
LAEPS Leadership
Contact Us
Home
Membership
— Join LAEPS
— Membership Applications
—— Online Application
— Membership Services
— Upcoming Events & Education Meetings
— Renew Membership
Eye Health
— What is an Ophthalmologist?
— Eye Smart Monthly Update
— EyeCare America
Advocacy
— LA Legislative Session
—— Legislation Tracker
—— Capitol Contact Info
— Find Your Legislators
— Quick Links & Resources
About Us
— Our Mission and Goal
— LAEPS Leadership
Contact Us
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.
Yes
Email
*
Business Phone
*
Mobile number (for internal use only)
Practice Administrator
*
Practice Administrator Email
*
Business Information
Specialty within Ophthalmology:
Type of Practice
*
Solo
Same Specialty Group
Multi-Specialty Group
Academic
Other
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
*
01
02
03
04
05
06
07
08
09
10
11
12
/
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
Card (CVV) Code
*
Card Type
*
Visa
MasterCard
Discover
American Express
Card Holder Name
*
Membership
Join LAEPS
Membership Applications
Online Application
Membership Services
Upcoming Events & Education Meetings
Renew Membership
© 2019 Louisiana Academy of Eye Physicians and Surgeons | Web Design by
Bruner and Company
Top
Member Login
Remember Me
Forgot your password?
Forgot your username?