MEMBER FORM

APPLICATION FORM TO JOIN PAN AFRICAN GLAUCOMA ASSOCIATION

Membership categories

There are currently two categories of membership. Confirm your eligibility before completion of the form.

Full members - Ophthalmologists with three (3) months or more cumulative formal sub-specialty training in glaucoma or Ophthalmologists with an interest in glaucoma with up to 25% of their time is spent in active clinical, academic or research in glaucoma care. Ophthalmologist must have completed a fellowship training in ophthalmology.  Annual membership dues for full membership is USD200= (Two hundred US Dollars).

Associate members - Ophthalmology Resident doctors currently in training. Certificate of ongoing training and reference from the Head of Department/Training must be submitted with the application. Annual membership dues for Associate membership is USD100= (One hundred US Dollars).

Applicant must submit the name of at least one referee who must be in good standing with the Association. Please submit the completed application form along with your resume and relevant supporting documents to email or online application.

Download Membership Form in PDF

    Professional Title:
    Full Name:
    Gender : MaleFemale
    Current Place of Employment/Practice:
    Type of practice: GovernmentPrivateCombined Government and PrivateNGO
    Others (specify):
    Practice Address Line 1
    Practice Address Line 2
    City:
    State:
    Zip Code:
    Country:
    Email Address:
    Phone Number (Work):
    Phone Number (Mobile):
    Membership details

    Type of membership

    1. Full membership
      a. How many months of cumulative glaucoma training?
      b. What approximate percentage of your clinical, academic or research time is for glaucoma care?
      c. Number of Years Practicing as Glaucoma Specialist/ in Glaucoma care:
      d. Professional Certifications and date:
    2. Associate membership
      a. How many months in ophthalmology residency training?
      b. Professional Certifications and date:
    Are you a member of any relevant professional organizations or associations? YesNo
    If yes, please specify:
    What committee(s) of the Association are you interested in? (Depending on availability).
    1. By-Laws committee2. Wet lab committee3. Conference planning committee4. Continuing Medical committee5. Fundraising committee6. Website communication, Press release and social media committee.7. Patient Education committee8. Research committee9. Membership committee10. Legislative committee
    How did you learn about Pan African Glaucoma Association? Online SearchReferralSocial MediaEvent/ConferenceOther
    If yes, please specify:
    Declaration:
    I declare that the information provided in this application is true and accurate to the best of my knowledge. I understand that any false statements may result in the rejection of my application. Applicant's Signature:
    Date

    Thank you for expressing your interest. We look forward to reviewing your application and welcoming you as a valued member.


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