Name of Endorser: ______________________________

Name of Applicant: ______________________________

Date: ______________________________

How long have you known the applicant? _______________________________________

In what setting did you observe the applicant?____________________________________

What was the applicant’s Department, Specialty and Status? ________________________

Please circle the response that best describes the applicant’s abilities in the following areas:

Medical Knowledge:

Technical & Clinical Skills:

Availability for & Thoroughness In Patient Care:

Ability to Cooperate and Work with Others:

Please use this section for any additional comments, information or recommendations which you believe relevant to our decision in granting membership.
_________________________________________________________________________

_______________________________________________________________________________
Signature PRINT NAME and Specialty

_______________________________________________________________________________
Date

Please complete the following and return to:
Houston Ophthalmological Society
7300 Brompton #6018
Houston, TX 77025

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