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LAEPS Membership Application

 

Personal Information



Business Information



Medical Education



Membership Type and Dues

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

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.
$