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:

Poor Marginal Average Good Excellent

Technical & Clinical Skills:

Poor Marginal Average Good Excellent

Availability for & Thoroughness In Patient Care:

Poor Marginal Average Good Excellent

Ability to Cooperate and Work with Others:

Poor Marginal Average Good Excellent


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
John P. McGovern Building
1515 Hermann Drive
Houston, TX 77004

.