WORLD FEDERATION OF ORTHODONTISTS APPLICATION FOR STUDENT MEMBER

Special Student Application

Valid September 19, 2013 through September 27, 2015
ANTONIO
JULIO
UGS
ZAPATA
1. I, _____________
_____________
_________________
_________________,
hereby apply to become a Student Member of the
First Name

Middle Name

Last Name

list degree (optional)

World Federation of Orthodontists (WFO) and agree to comply with its charter, Bylaws and policies.

CALLE 21 725 DEPARTAMENTO 204

2. Home Address ____________________________________________________________________________________________
LIMA

27
LIMA
PER
City _________________________ State/Province __________________
Zip Code ___________
Country _______________
1
980713534
051
Home Telephone # __________
_________
________________
Home Fax # __________ _________ ________________
(Country Code)

(City Code)

(Telephone #)

(Country Code)

(City Code)

(Fax #)

juliougaszapata@icloud.com
Personal E-mail address _____________________________________________________________________________________
PER
3. A. I am a citizen of ________________________

08
23 _______
1985
B. My date of birth is _____________
_____

(Country)

(Month)

(Day)

C. Male or Female

(Year)

(Circle one)

COLEGIO ALGARROBOS
4. I completed my pre-dental college education at ___________________________________________________________________
(name of university, hospital, institution, etc. DO NOT ABBREVIATE)

CHICLAYO, PER
1991
2002
in _____________________________________________________
from ____________________
to ____________________
(City, Country)

(Date)

(Date)

UNIVERSIDAD INCA GARCILASO DE LA VEGA

5. I completed my dental education at ____________________________________________________________________________
(name of university, hospital, institution, etc. DO NOT ABBREVIATE)

2010
LIMA, PER
2004
in _____________________________________________________
from ____________________
to ____________________
(City, Country)

(Date)

(Date)

UNIVERSIDAD CIENTFICA DEL SUR

6. I am currently enrolled as a post-graduate orthodontic student, in good standing, at ______________________________________
(Name of university, hospital, institution, etc. DO NOT ABBREVIATE)

LIMA, PER
located in ____________________________________________.
(City/State/Country)

03 years (not to exceed five years.)

7. I will be a post-graduate orthodontic student for ______
ABRIL 2015
8. Expected date of completion of orthodontic education: _____________________________________________________________
I, the person named above, do swear under oath that the answers to all questions on this application are true and complete to the best of
my knowledge and that I am qualified to be a Student Member of the WFO. I also understand and agree that the WFO may investigate my
qualifications. I further waive the right to hold the WFO, its affiliates, executive committee, officers, members and employee responsible for
any damage as a result of the denial of this application or any other action taken by the WFO.

Applicant Signature _______________________________________________________________

Student Membership Application continued on reverse side

19/11/2014
Date ______________________

Mandatory Certification/Verification for Student Membership

Certification of Enrollment
I hereby, do certify that the stated applicant is enrolled as a post-graduate orthodontic student at the stated institution, at which I
am employed.
_______________________________________

______________________________

(Print name of dean, orthodontic department chairman or program director)

_______________________________________

(Title)

_________________________________________
(E-mail address)

______________________

(Signature of dean, orthodontic department chairman or program director)

(Date)

Verification of Eligibility
I, ________________________________________, President of the _____________________________________________
(Print Presidents name)

(Name of national orthodontic organization)

have examined the certification of post-graduate status in orthodontics for _______________________________________ and
(Applicants name)

verify that he/she is eligible to become a Student Member of the World Federation of Orthodontists.

___________________________________

______________________

(Presidents signature)

(Date)

The WFO Executive Committee voted at their meeting on September 19, 2013 to suspend payment of the first two years of WFO
dues for residents who make application from September 19, 2013 to September 27, 2015.
Therefore, no payment is required at this time. You will be enrolled as a student member for 2 years. You will receive a renewal
invoice about two months prior to your expiration date.
The expiration date of your membership will be noted on your membership card.
Please mail the completed form to:
World Federation of Orthodontists
401 North Lindbergh Boulevard
St. Louis, Missouri 63141-7816,
USA
Fax: +1-314-985-1036
email: WFO@WFO.org

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