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:

Group three

Home Address:

Paypal

Billing Information:

Group three

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:

Active, Corresponding, Professional, and Vision 20/20 Applicants

Please submit a letter of recommendation from a current Active AES member to complete your membership application. Click here for the recommendation letter form.

Junior Applicants

Please provide a letter confirming your status as a trainee to complete your membership application. Click here for the form that should be completed by your program director.

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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