REQUEST FOR REDUCTION or WAIVER OF AOA ANNUAL MEMBERSHIP DUES

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REQUEST FOR REDUCTION OR WAIVER OF AOA ANNUAL MEMBERSHIP DUES

We are happy to consider request for a reduction or waiver of the annual dues for active AOA members. The Bureau of Membership carefully reviews the documentation provided by you and grants dues reductions and waivers as deemed appropriate; however, the Bureau does request some evidence of need. Please note, physicians that are no longer practicing due to retirement may qualify for a permanent reduced dues rate. Please contact the Member Resource Center for more information.

Section 1: Member Information

AOA ID: (example: 000000)

Name*

First Name

Initial (optional)

Last Name

Email*

Preferred Phone Number:*

Home Business

Phone (example: 000-000-0000)*

Is this your first request for a consideration of waiver of your annual membership dues?*

Yes No

Please select the nature of your current circumstance:

Type of Reduction: *

Reduction to ½ annual dues rate Reduction to $104.00 Full dues amount waived

Section 2. Evidence of Need: Waiver for Financial Need

Please indicate the status of your practice and/or your professional employment:*

Full-time practice (20 hours or more per week) Part-time practice

Part-time practice, how many hours per week:

Last year, my Adjusted Gross Income was* $

Are you engaged in other types of professional employment? *

Yes No

If yes, please explain:

Are you currently a member of your state osteopathic association?*

Yes No

If yes, have you received a reduction/waiver in your state association dues?*

Yes No

Section 2. Evidence of Need: Waiver for Medical Condition

You are asked to provide two forms of documentation with this request: Member Release Authorization and Attending Physician Statement. Links to the forms are provided below. A letter from your attending physician is also acceptable to submit with request.

Member Release Authorization Form: Member Release Authorization Form

Attending Physician Statement Form: Attending Physician's Statement

Member Release Authorization Form*

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Attending Physician Statement/Attending Physician Letter*

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Section 2. Evidence of Need: Waiver for Maternity

Waivers are granted for the first and second year after the birth of a child or date of adoption.

Child's Date of birth/adoption:*

Attestation of Need*

I understand that this waiver is granted for two consecutive fiscal years and I must submit a new application for any subsequent waiver requests, maternity or otherwise.

Section 2. Evidence of Need: Waiver for Active Military Deployment

Date of Deployment*

Deployment Location*

Start Date of Service *

Return Date from Service*

Please upload a copy of your recent military orders which indicate current deployment status*

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Additional Supporting Information (if necessary)

Section 2. Evidence of Need: Waiver for Other Extenuating Circumstances

Examples: Death of family member; Pursuit of continued education/advanced degree; Care for family member; Sabbatical; etc.)

Please provide details of your current circumstances in the previous fiscal year that have affected a hardship. *

Section 3. Supporting Documentation

Please upload any additional supporting documentation (if needed):

Upload Supporting Documents:

Financial: If more space is needed
Medical Condition: If additional documentation is needed
Maternity: If more space is needed
Active Military Deployment: If additional documentation is needed
Other Extenuating Circumstances: If more space is needed

Additional Documentation

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Section 4. Attestation of Statement of Need

I attest that the information provided is accurate. I also understand that this request is only applicable to my AOA membership dues. I am responsible for payment of any fees related to Osteopathic Continuous Certification, Certification Exams, Conference Registrations, or any other AOA products or services.

Signature*

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Date*