Membership Form

It takes approximately 2-4 weeks for your AES membership application to be fully processed.

Electronic notifications will be sent to keep you posted during the application process. Applications submitted prior to April 1, 2015 will be processed for the new Membership year , July 1, 2015 -  June 30, 2016.

Special Rate for First Time RESIDENTS / STUDENTS / FELLOWS (Junior Membersip) applicants: New Resident/Student/Fellow applicants receive a special first year-only rate of $35 ($110 with Epilepsia).

Click here for PDF version of Membership Form

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Group One

All applicants must complete the following * are required.

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Business Address:

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Home Address:

Paypal

Billing Information:

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Education:

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Junior Membership Applicants:

A statement from the training or program director under which the applicant is training is required to complete this application. Please email the statement to membership@aesnet.org or fax to 312.896.5784 and include the name of the applicant.

ACTIVE, CORRESPONDING, PROFESSIONAL IN EPILEPSY CARE AND VISION 20/20 PARTNER APPLICANTS:

A statement of sponsorship from a currently active Member of AES is required to complete this application. Please email the statement to membership@aesnet.org or fax to 312.896.5784 and include the name of the applicant.

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MEMBERSHIP CATEGORIES

sponsorship:

Submission of a statement of sponsorship is required for this application to be considered complete for Active, Corresponding, Professional, Vision 20/20 Partner, and Junior Members. This statement can be emailed directly to membership@aesnet.org or faxed to 312.896.5784

(Associate applicants are not required to submit a letter of sponsorship with this application.)

Profession:

areas

Payment Information

Membership Level:

Charge Amount:

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*Card Number
*Expiration
Date
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VISA/MC

AMEX

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