AAOMS MAILING LIST REQUEST FORM
Please type or print clearly.

____________________________________________________________________________________________________________Contact NameTitle____________________________________________________________________________________________________________Company____________________________________________________________________________________________________________
Address
Suite/Floor
CityStateZIP Code____________________________________________________________________________________________________________
EmailPhone
DESIRED DEADLINE DATE: ______________________________________________________________________________________
REQUESTED BY:
 AAOMS Member Exhibitor

 AAOMS Advantage Partner
LIST SORT ORDER:
 Alphabetical Educational Institution (Hospitals, Universities)

 AAOMS Staff

 ZIP Code Regional or State OMS Society Other _________________________________________________________

 StateTYPE OF LIST REQUESTED: Annual Meeting pre-reg. list

 Annual Meeting informational pre-reg. list (name, company, city and state only) Annual Meeting post-reg. list

 Annual Meeting informational post-reg. list (name, company, city and state only) Dental Implant Conf. pre-reg. list

 Dental Implant Conf. informational pre-reg. list (name, company, city and state only) Dental Implant Conf. post-reg. list

 Dental Implant Conf. informational post-reg. list (name, company, city and state only) Entire Membership (This includes residents in training, practicing OMSs, retired OMSs, non-OMS members, and international OMSs.) Practicing OMSs (This includes private practice, faculty, federal service, and international OMSs.) Resident Members (This includes all residents currently enrolled in OMS training programs.)
 Other: ___________________________________________________________________________________________________
LOCATION REQUESTED: United States
 North America
 District I (CT, MA, ME, NH, NY, RI, VT)

 All geographic regions
 District II (DC, DE, MD, NJ, PA) District III (AL, FL, GA, KY, LA, MS, NC, SC, TN, VA, WV, PR, Guam, Virgin Islands)  District IV (IL, IN, MI, OH, WI)
 District V (AR, CO, IA, KS, MN, MO, MT, ND, NE, NM, OK, SD, TX, WY) District VI (AK, AZ, CA, HI, ID, NV, OR, UT, WA) Other: __________________________________________________________________________________________________
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MAILING LIST POLICY: Purchase of a mailing list is for one-time use only and is not to be duplicated in any manner. Allow atleast seven business days for AAOMS to process your request. AAOMS does not release member email addresses, phone numbers or fax
numbers for any purposes. AAOMS policy prohibits use of the mailing list for recruitment purposes. AAOMS Today Classifieds(AAOMS.org/classifieds) and AAOMS Career Line (healthecareers.com/AAOMS) are available for this purpose.
A general membership mailing list and a list of meeting registrants may be provided for a fee to fellows, members, candidates andresidents; regional and component OMS societies; educational institutions; exhibitors; peer partners and non-members in accordancewith the following:• Mailing lists are protected by copyright and shall not be duplicated without written permission of the Executive Director ofAAOMS.
• Oral and maxillofacial surgery institutions, fellows and members who sponsor courses for a profit and wish to announce themto AAOMS membership will be charged the exhibitor/commercial fee for a mailing list.
• Fellows and members who wish to conduct a scientific survey of the membership may purchase a mailing list at a reducedfee.
• AAOMS reserves the right to deny requests where the purpose or use may be considered not in the best interest of theAssociation or its purposes.
Residents may purchase a mailing list at a reduced fee.
In accordance with the requirements of the Accreditation Council for Continuing Medical Education (AACME), only those who haveopted-in to receive marketing communications will be included in the mailing list(s) for CE activities.
EXHIBITORS: As a condition of granting exhibit space at AAOMS meetings, exhibitors agree not to conduct or sponsor any educationalseminars on the dates of the AAOMS meeting. Exhibitors may conduct or host an event such as a breakfast, luncheon, dinner, reception
or focus group on the dates of the meeting during non-programming hours as determined by AAOMS. An exhibitor may conduct orsponsor an education seminar immediately preceding or immediately following the meeting program. All requests to holdnon-educational or educational functions must be submitted for review and approval to the AAOMS Exhibits Manager. Final version ofmailing content is required for review by Exhibits manager before a mailing list will be provided.
REGIONAL AND STATE OMS SOCIETIES: As approved by the AAOMS Board of Trustees, each state and regional OMS Society is allowed
up to two sets of mailing lists per calendar year at no charge. Additional sets may be purchased at the regular price.
PRICES:Annual Meeting pre-reg.
Dental Implant Conf. pre-reg.
Single District

$ 350
$ 275
$ 300

Annual Meeting post-reg.
Dental Implant Conf. post-reg.
Single U.S. State

Entire Membership
Practicing OMSs
Resident Members$ 1000$ 1000$ 250

Approximately 11,000+ members
Approximately 6,800+ members
Approximately 1,260+ members

$ 475
$ 325
$ 200

Sample mailing pieces are acceptable for initial review. Exhibitors are required to provide final version for review.
Mailing pieces should be emailed to membership@aaoms.org. Completed request form with payment details should besecurely faxed to 847-678-6279.
 American Express Discover MasterCard

 Visa  Check (mail to AAOMS)___________________________________________________________________________________________________________Credit card #CVV#Expiration date____________________________________________________________________________________________________________
Cardholder Name (please print)
Cardholder Signature____________________________________________________________________________________________________________
Billing Address
Suite/Floor
City
State
ZIP CodeSign below to confirm you read and agree to the Mailing List Policy described in this request form. Your request will not be reviewed
without acknowledgement and signature below.
____________________________________________________________________________________________________________Signature
Date of Request
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