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* 1. First Name:

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* 2. Last Name:

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* 3. Email Address:

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* 4. NANOS Membership Category:

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* 5. Indicate your training background (check all that apply):

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* 6. Indicate your current position (check all that apply):

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* 7. Please check if you have specific interest or expertise in the following topics (select all areas of your expertise/interest that NANOS can benefit from) :

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* 8. NANOS is particularly in need of people with expertise in the business aspects of neuro-ophthalmology and advocating for our discipline. Please indicate whether you have expertise in the following areas OR a desire to learn these skills (select all that apply)

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* 9. Indicate your area(s) of interest in the NANOS Organizational Development:

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* 10. Are you willing to serve in an area other than your primary interest if we feel that your skillset will best suit NANOS in a different area?

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* 11. With the expansion of NANOS's goals and activities, we need more members who are willing to serve in leadership roles and help drive NANOS's mission. Are you interested in chairing or co-chairing a committee?
NOTE that members who have chaired NANOS committees, have a good working knowledge of NANOS, a track record of devoting time and energy to the organization, and proven leadership ability are usually nominated and approved for NANOS Board of Directors seats. 

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* 12. Please contact me, as I would like to donate to the Society:

Thank you for your willingness to contribute to the success of NANOS!

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