Membership Application | North American Neuro-Ophthalmology Society

Membership Dues

Your Dues Rate Type is: Pending Fellow-in-training $275.00

Contact Information

Email *

Confirm email address *

Prefix

First Name *

Middle

Last Name *

Suffix

Title

Informal Name

Company

Address 1 *

Address 2

Address 3

City *

State

Zip Code *

Country

Website

Phone Number *

Fax Number

CCMail

Include me in Membership Directories *
Yes No

Types of emails you would like to receive: *

Subscribe me to NANOS General News and Updates

Subscribe me to Carefully Curated Promotional Messages (i.e. free CME courses, webinars, podcasts, etc.)

Subscribe to receive messages related to free CME credit offerings or other content or products that is of interest to Neuro-Ophthalmology professionals. Please note that the content in these e-blasts is carefully curated, yet it should not be considered a NANOS endorsement or recommendation.

None - do not send me any email marketing messages

Member Login/Password

Please enter the Member Login/Password you would like to use to login to this website.

Your Member Login must be unique and must be at least 6 characters.
Passwords must be a minimum of 8 alpha-numeric characters with at least 1 number or 1 letter.

Member Login *

Password *

Confirm Password *

Additional Information

Payment Details

Payment Method

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Account Type

Checking

Savings

Routing Number

Account Number

Account Holder Type

Business

Personal

Business Name

Account Holder Name

By submitting payment, I am authorizing North American Neuro-Ophthalmology Society to initiate a single or recurring ACH/electronic debit in the amount indicated from the bank account I designated above. I understand that this Authorization will remain in full force and effect until the transaction is cancelled by me by contacting North American Neuro-Ophthalmology Society, or the ACH/electronic debit is processed from the designated account. I certify that (1) I am authorized to debit the bank account above and (2) the ACH/electronic payment I am authorizing complies with all applicable laws.

Name on Card

Card Number

Expiration

CSC

Billing Street

Billing Zip Code

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Total Amount Due

$

1935 County Road B2 W Ste 165 \| Roseville, MN 55113
	952.646.2037		info@nanosweb.org meetings@nanosweb.org

Fellow-in-Training Membership Application

Membership Dues

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Contact Information

Member Login/Password

Additional Information

Payment Details