Institutional Membership Application Form Name of Institution *Date of Establishment *Country of Registration *Office Address *Phone Number *Website *Person-In-Charge *FirstLastPosition *Email *Contact Person *FirstLastPosition *Email *Type of Institution *HospitalClinicUniversityResearch InstituteTelemedicine Management CompanyTelemedicine Technology CompanyOphthalmic CompanySociety/AssociationCommunity Service OrganizationWhat services does your institution provide? Please specify the scope of work. *Briefly state your experience in ophthalmology and/or tele-ophthalmology: *Category *Regional Member (for applicants based in the Asia-Pacific region)Associate Member (for applicants based outside the Asia-Pacific region)Declaration *By applying for membership with the Asia Pacific Tele-Ophthalmology Society, we hereby agree to abide by the Society’s Constitution and By-laws upon successful application.PhoneSubmit
