Certification : Application for Clinical Examination The Clinical Examination is conducted at your practice hospital(s) usually during the months of June, July, and August. Time and place will be determined by you and the senior examiner. To send an Application for Oral Examination to the AOBOS, fill out the form below and click the [Submit] button. You must also submit the following via mail to the address below: An examination fee of Two Thousand Dollars ($2000.00). If not accepted for examination, the Board will return eighteen hundred dollars ($1,800.00). Typewritten or computer generated logs containing 200 or more major orthopedic cases. Log all cases for two (2) years prior to December 31 of the year immediately preceding your application. You must be in practice one full calendar year prior to application. A copy of most recent AOA CME report. A copy of your license. Affidavit from hospital administrator or medical director attesting that your practice is 75% Orthopedic medical and surgical practice. Submit To: Marikay M. Finnell Executive Secretary AOBOS 805 Sir Thomas Ct Harrisburg, PA 17109 717 / 561-8560 717 / 652-9297 FAX Your application must reach the Executive Secretary's office prior to February 15 of the year of the examination. The application for clinical examination and your logs will be reviewed by the Board and notification of acceptance or denial will be given approximately two (2) months prior to the examination. By clicking "I AGREE" below, I hereby affirm that the case logs attached to this application are surgical cases performed by me and are not first assists or the work product of any other person, and that further, I have been a member in good standing of the American Osteopathic Association for a period of more than two (2) years prior to the submission of this application. DEADLINE FOR APPLICATION IS FEBRUARY 15 (Logs recieved after Feb. 15th will be returned) Name Dated AOA No. Address City, State, Zip , Phone Address Current Until* If moving, please complete a change of address form as well. READ THE FOLLOWING, AND CLICK "I AGREE" BELOW TO SUBMIT THE APPLICATION. CLICK "RESET" BELOW TO CLEAR THE FORM AND START OVER. I hereby make application to the American Osteopathic Board of Orthopedic Surgery (AOBOS) for examination leading to certification in Orthopedic Surgery. This action is made in accordance with and subject to the Constitution, Bylaws, Regulations, and Requirements of the AOBOS and the American Osteopathic Association (AOA). I understand that the certifying examination is a proprietary document of the AOBOS and AOA, and that I do not and will not have the right to review the examination or any examination questions at any time prior to or following the administration of the examination. I agree to disqualification from examination or from issuance of certification or to the surrender of such certification as directed by the AOBOS and/or the AOA in the event that any of the statements made by me in this application are false, or in the event any of the bylaws, rules, regulations, and requirements governing such examinations are violated by me, or in the event that I do not comply with any of the provisions of the Constitution, Bylaws, Regulations, or Requirements of the AOBOS or the AOA. I agree that my professional qualification, including my moral and ethical standing in the osteopathic medical profession and my competence in clinical skills will be evaluated by the Board and that the Board may make inquiry of the persons named in my application and of other persons such as authorities or licensing bodies, hospital, program directors, and other institutions as the Board may deem appropriate with respect to such matters; and I agree that the sources of all information furnished to the Board in connection with its inquiry shall be confidential and not subject to disclosure, through legal process or otherwise, to me or any persons acting on my behalf. I agree that the AOBOS and the AOA shall be the sole judges of my credentials and qualifications for admission to the examination for certification. I hereby release, discharge, exonerate, and agree to hold harmless the AOBOS, the AOA, their members, examiners, trustees, officers, representatives, and agents and free from any action, suit, obligation, damage, expense, claim, demand, or complaint by reason of any action they or any one of them may take in connection with this application, such certifying examinations, the grade or grades given with respect to any certifying examination, and/or failure of the AOBOS to recommend issuance to me of the certification, or the revocation of any certification issued pursuant to this application. It is understood that the decision as to whether my performance on any certification examination qualifies me for certification rests solely and exclusively with the AOBOS and the AOA, and that their decision is final. In the event that any dispute shall arise concerning the certification examination and or administration, or any other issue relating to the certification process, I understand that the AOA has an administrative appeal process available and I agree to first pursue all available administrative appeals and internal reviews before pursuing any other forms of relief. I further agree that Illinois law shall apply to the resolution of any dispute that I may have with the AOBOS or AOA. I have this date carefully read and agreed to full compliance with the foregoing.