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The Academy of Osseointegration was founded as a regional study club following theintroduction of osseointegrated implants to the dental profession in 1985. The organization hasgrown 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 nationsand a spectrum of disciplines. The Academy’s membership is comprised of doctors and alliedstaff from all levels of dentistry who are committed to thebest care for their patients based on time-testedtechnologies, along with presentations of cutting-edgeinnovations. Many of these individuals have given theirtime and expertise to dental education, research andservice to the Academy and the implant profession. Themembership is a cross-section of “Who’s Who” in thedental implant and biosciences arena, including dentalschool deans, program directors, journal editors, andinternational research scientists and lecturers.

Reflecting the importance of science and service embodied in its founding principles, theAcademy established a Fellow membership category to honor those individuals who have madeoutstanding 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 isattainable by all members.

While not a form of credentialing, the AO Board of Directors believes that attaining Fellowshipof the Academy says more about our members than mere case presentations or examination ofknowledge. It sets the standard for those who take their continuing professional educationseriously, have a strong commitment to the field of implant dentistry and recognize theincredible value that volunteerism and philanthropy have in an organization.

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

Successful candidates will be recognized by presentation of aFellowship certificate and pin during the Opening Session ofthe Annual Meeting and their names will be published in theAcademy News and the Membership Directory foracknowledgment of the entire membership.

Please review the enclosed application formwithin this brochure and start workingtowards 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 60005Phone: (847) 439-1919 or (800) 656-7736

FAX: (847) 427-9656Email: 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 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 Date of Birth

Company/Institution

Mailing Address (Include room, suite, etc.)

City State/Province Zip/Postal Code

Country Phone (include country code) Fax (include country code)

E-Mail Address

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, ineither a clinical or research setting or working in an implant-related academic position minimum three days/week. (Excludingpost-graduate training/research.)

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

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

Please list the years in which you have been an Active 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 the most recent AO Membership Directory for a listing of Fellows of the Academy.)

Please list each Fellows’ name:

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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.

Committee Member – (1 point per completed year)

Committee Chair – (1.5 points per completed year)

AO Ambassador – (1 point per completed year)

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

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

COMMITTEE NAME YEAR POINT(S)

TOTAL POINTSFROM SECTION 1

COMMITTEE NAME YEAR POINT(S)

COMMITTEE NAME YEAR POINT(S)

COMMITTEE NAME YEAR POINT(S)

COMMITTEE NAME YEAR POINT(S)

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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 ofparticipation 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 article on implant dentistry or related area ofresearch in IJOMI.(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 ofresearch 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 relatedarea of research.(1 point per chapter – maximum of 2 chapters)If you are submitting more than one chapter, please list the quantity here: __________

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: __________

REQUIREMENTS – SECTION 3: PRESENTATIONS

Four (4) points are required from Section 3.

Please indicate the presentation type.

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

POINT(S)

POINT(S)

POINT(S)

POINT(S)

POINT(S)

POINT(S)

TOTAL POINTSFROM SECTION 2

PRESENTATION NAME YEAR PRESENTED POINT(S)

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REQUIREMENTS – SECTION 3: PRESENTATIONS (continued)

Academy of Osseointegration Annual Meeting Abstract Presentation (Scientific or Clinical) – (1 point per meeting)

Academy of Osseointegration Lunch and Learn Presentation – (1 point per meeting)

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

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

Academy of Osseointegration Charter Chapter Presentation – (2 points per meeting)

POINT(S)PRESENTATION NAME YEAR PRESENTED

PRESENTATION NAME YEAR PRESENTED POINT(S)

PRESENTATION NAME YEAR PRESENTED POINT(S)

PRESENTATION NAME YEAR PRESENTED POINT(S)

POINT(S)PRESENTATION NAME YEAR PRESENTED

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REQUIREMENTS – SECTION 3: PRESENTATIONS (continued)

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

Academy of Osseointegration e-Poster Moderator – (1 point per meeting)

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

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

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

*Supporting presentation documents are required with application submission.

POINT(S)PRESENTATION NAME YEAR PRESENTED

PRESENTATION NAME YEAR PRESENTED POINT(S)

PRESENTATION NAME YEAR PRESENTED POINT(S)

POINT(S)PRESENTATION NAME YEAR PRESENTED

POINT(S)PRESENTATION NAME YEAR PRESENTED SPONSORING ORGANIZATION

TOTAL POINTSFROM SECTION 3

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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 above – (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 bedetermined 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 dentalgraduation, or higher educational degree, all CERP certificates (or local equivalent evidence of further continuing education),and certificates of attendance to Academy of Osseointegration and other meetings. In addition, any evidence to support yourapplication, such as copies of conference programs in which you have lectured or article reprints, etc., is advised to help speedup 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 varietyof activities, the Academy of Osseointegration Board and Fellowship and Certificate Committee reserve the right to includeadditional activities not listed or exclude activities deemed inappropriate. Any decision to exclude an activity that might resultin failure to obtain Fellowship will be explained to the applicant in full.

TOTAL POINTSFROM 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 andall supporting documents to:

Academy of OsseointegrationAttn: Fellowship and Certificate Department

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

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

Fax: (847) 427-9656 or Website: www.osseo.org

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