Application for Fellowship

Advancing the Vision of Implant Dentistry osseo.org

The Academy of Osseointegration was founded as a regional study club following the introduction of osseointegrated implants to the dental profession in 1985. The organization has grown exponentially, paralleling the explosion of basic and clinical science in implant dentistry. AO is a broad-based dental association with a large membership, drawn from over 65 nations and a spectrum of disciplines. The Academy’s membership is comprised of doctors and allied staff from all levels of dentistry who are committed to the best care for their patients based on time-tested technologies, along with presentations of cutting-edge innovations. Many of these individuals have given their time and expertise to dental education, research and service to the Academy and the implant profession. The membership is a cross-section of “Who’s Who” in the dental implant and biosciences arena, including dental school deans, program directors, journal editors and international research scientists and lecturers.

Reflecting the importance of science and service embodied in its founding principles, the Academy established a Fellow membership category to honor those individuals who have made outstanding contributions to the Academy of Osseointegration and implant dentistry in general. Criteria has been established to offer a careful balance of requirements that will ensure it is attainable by all members.

Attaining Fellowship in the Academy says more about our members than mere case presentations or examination of knowledge. It sets the standard for those who take their continuing professional

education seriously, have a strong commitment to the field of implant dentistry and recognize the incredible value that volunteerism and philanthropy has to an organization.

The opportunity to be honored as an exclusive Fellow of the Academy of Osseointegration is one that every AO member should aspire to.

Successful candidates will be recognized by presentation of a Fellowship certificate during the Opening Session of the Annual Meeting and their names will be published in the Academy newsletter for acknowledgment to the entire membership.

Please review the application form within this brochure and start working towards your own Fellowship goal today.

Academy of OsseointegrationAdvancing the Vision of Implant Dentistry

ACADEMY OF OSSEOINTEGRATIONAPPLICATION FOR FELLOWSHIP

85 W. Algonquin Road, Suite 550, Arlington Heights, IL 60005 Phone: (847) 439-1919 or (800) 656-7736

Fax: (847) 427-9656 Email: membership@osseo.org Website: www.osseo.org

APPLICATION INSTRUCTIONS: A minimum of fifteen (15) points total is required for the application to qualify for Fellowship. There is no cross compensation of points between sections 1-3. However, if the required points within sections 1-3 are not met, points from section 4 can be applied to compensate for the difference. Applicants are responsible for providing and labeling all required and supporting documents. Please complete the following sections as instructed and submit application with all the supporting documents to the AO Executive Office.

PLEASE TYPE OR PRINT. ILLEGIBLE OR INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED.

APPLICANT INFORMATION

Last Name First Name Middle Initial Degrees

NPI Number (if licensed in US) Date of Birth

Company/Institution

Mailing Address (Include room, suite, etc.)

City State/Province Zip/Postal Code

Country Phone (include country code)

Email Address Specialty

n I agree to receive AO updates, announcements, news and promotions by mail and email.

Signature Date

PRE-APPLICANT REQUIREMENTS

The following prerequisites are required of applicants:

1. Applicant must be a qualified DMD/DDS/PhD or equivalent, with a minimum of ten years, actively involved in dentistry, in either a clinical or research setting or working in an implant-related academic position minimum three days/week. (Excluding post-graduate training/research.)

Please provide copies of DMD/DDS/PhD (or equivalent) certificate identifying year of graduation and a letter from your head of department confirming your contractual commitments and/or evidence of your involvement in private practice.

2. Applicant must be a member of Academy of Osseointegration for five (5) consecutive years.

Please list the years in which you have been a member of the Academy of Osseointegration:

3. Applicant must have attended a minimum of three (3) Academy of Osseointegration Annual Meetings within the last seven (7) years.

Please list which three (3) years you have attended the Academy of Osseointegration Annual Meetings:

4. Applicant is required to provide supporting testimonials from two (2) current Fellows of the Academy of Osseointegration. (Please refer to AO’s website for a listing of Fellows.)

Please list each Fellows’ name:

1

REQUIREMENTS – SECTION 1: SERVICE

Six (6) points are required from Section 1.

Please list the roles and years of service you have provided to the Academy of Osseointegration.

AO/OF Executive Committee/Officer Positions – (3 points per completed year)

POSITION YEAR(S) POINTS

AO/OF Board of Directors – (2 points per completed year)

POSITION YEAR(S) POINTS

Organize a Charter Chapter Meeting or University-based Program/Study Club – (1 point per completed year)

MEETING OR PROGRAM YEAR(S) POINTS

Committee Chair – (1.5 points per completed year)

COMMITTEE NAME YEAR(S) POINTS

Committee Member – (1 point per completed year)

COMMITTEE NAME YEAR(S) POINTS

TOTAL POINTS FROM SECTION 1

2

REQUIREMENTS – SECTION 2: STUDY & PUBLICATIONS

Five (5) points are required from Section 2.

Please indicate and label the documentation and/or publications to be submitted with the application.

Submission of seven consecutive years of implant related ADA-CERP verification of participation documents (or local equivalent evidence of further continuing education). Requirement is a minimum of 210 hours (not including company-specific courses).

(4 points)

Evidence of having obtained a higher degree in a University-based Implant Program (Masters or equivalent only) or completion of residency program in mono-specialty.

(3 points)

Authored or co-authored, a published textbook in implant dentistry or related area of research.

(3 points per book) If you are submitting more than one textbook, please list the quantity here: __________

Authored or co-authored, a published article on implant dentistry or related area of research in IJOMI or IJPRD.

(2 points per article) If you are submitting more than one article, please list the quantity here: __________

Authored or co-authored, a published article on implant dentistry or related area of research any other peer-reviewed journal.

(1 point per article) If you are submitting more than one article, please list the quantity here: __________

Authored or co-authored, a published textbook chapter on implant dentistry or related area of research.

(1 point per chapter – maximum of 2 chapters) If you are submitting more than one chapter, please list the quantity here: __________

REQUIREMENTS – SECTION 3: PRESENTATIONS

Four (4) points are required from Section 3.

Please indicate the presentation type.

Academy of Osseointegration Plenary Session Presentation – (3 points per meeting)

POINTSPRESENTATION TITLE YEAR PRESENTED

POINTS

POINTS

POINTS

POINTS

POINTS

POINTS

TOTAL POINTS FROM SECTION 2

3

REQUIREMENTS – SECTION 3: PRESENTATIONS (continued)

Academy of Osseointegration Limited Attendance Lecture Presentation – (2 points per meeting)

POINTSPRESENTATION TITLE YEAR PRESENTED

Plenary program presentation on implant related subject at any conference sponsored by the following: AAOMS, AAP, ACP, ADA, AGD, EAO, IADR, FDI or other non-commercial organization* – (2 points per meeting)

POINTSPRESENTATION TITLE YEAR PRESENTED SPONSORING ORGANIZATION

*Supporting presentation documents are required with application submission.

Academy of Osseointegration Charter Chapter Presentation – (1 point per meeting)

POINTSCOUNTRY PRESENTATION TITLE YEAR PRESENTED

Academy of Osseointegration Annual Meeting Moderator – (1 point per meeting)

POINTSSESSION TITLE YEAR PRESENTED

Academy of Osseointegration E-poster Moderator – (1 point per meeting)

POINTSYEAR MODERATED

4

REQUIREMENTS – SECTION 3: PRESENTATIONS (continued)

Academy of Osseointegration Round Table Clinic Presentation – (1 point per presentation)

POINTSPRESENTATION TITLE YEAR PRESENTED

Academy of Osseointegration Morning With the Masters, Lunch With the Masters or

Lunch and Learn Presentation – (1 point per presentation)

POINTSPRESENTATION TITLE YEAR PRESENTED

Academy of Osseointegration Annual Meeting Abstract Presentation (Oral Research, Clinical Innovation E-poster or Poster) – (1 point per presentation)

POINTSPRESENTATION TITLE YEAR PRESENTED

Academy of Osseointegration Webinar – (1 point per presentation)

POINTSPRESENTATION TITLE YEAR PRESENTED

TOTAL POINTS FROM SECTION 3

5

REQUIREMENTS – SECTION 4: OUTREACH AND PHILANTHROPY

Points are not mandatory from this section.

Please indicate the amount donated to the Osseointegration Foundation to date or if you have completed Outreach activity. (Previous donations in the below amounts can be applied to Section 4.)

Osseointegration Foundation Donations of $10,000 or more – (3 points)

Osseointegration Foundation Donations between $5,000 -$9,999 – (2 points)

Osseointegration Foundation Donations between $2,000 - $4,999 – (1 point)

Any outreach activity which fulfills the Academy of Osseointegration’s mission statement* – (1 point)

* Please provide appropriate evidence and testimonials of support. Qualifying outreach activities will be determined by the Fellowship and Certificate Committee.

POINT TOTAL

SUPPORTING DOCUMENTS

Please provide copies of certificates only, as these are required for verification. You should include your certificate of dental graduation, or higher educational degree, all CERP certificates (or local equivalent evidence of further continuing education), certificates of attendance to Academy of Osseointegration/other meetings and your Curriculum Vitae. In addition, any evi-dence to support your application, such as copies of conference programs in which you have lectured or article reprints, etc., is advised to help expedite the process.

DISCRETION OF THE BOARD

Please be advised that while every effort has been made within the context of this point system to be inclusive for a variety of activities, the Academy of Osseointegration Board and Fellowship and Certificate Committee reserve the right to exclude activities deemed inappropriate. Any decision to exclude an activity that might result in failure to obtain Fellowship will be explained to the applicant in full.

TOTAL POINTS FROM SECTION 4

TOTAL POINTS FROM SECTION 1

TOTAL POINTS FROM SECTION 2

TOTAL POINTS FROM SECTION 3

TOTAL POINTS FROM SECTION 4

GRAND TOTAL

Return the completed application and all supporting documents to:

Academy of Osseointegration Attn: Membership Department

85 West Algonquin Road, Suite 550 Arlington Heights, IL 60005

Email: membership@osseo.org Fax: (847) 427-9656

For questions or more information, please contact the Academy of Osseointegration at 847-439-1919 or membership@osseo.org.

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