Type of membership requested: Categories of Membership Note: Initial application must be for Associate (Unaccredited) Membership. Accreditation is a separate process. For more information on EBAA Accreditation, visit http://www.restoresight.org/eye-bank-accreditation/. For information about membership dues, contact Molly Georgakis, Vice President, Members Services. Legal name of eye bank: Other names or IDs under which the eye bank operates: Date/place of incorporation: Address: Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombi Comoros Congo (Brazzaville) Congo Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Timor Timur) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Morocco Mozambique Myanmar Namibia Nauru Nepa Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Country Phone Fax: E-mail: Web address: Date of incorporation or founding: How is the eye bank funded? Check all that apply: If other, please specify: Is the organization a not-for-profit? Attach a copy of the 501(c)(3) or 501(c)(6) tax-exempt status letter or a letter of determination. How is the organization controlled or governed? If part of a larger organization, please specify: Does the eye bank have a Board of Directors? If yes, please attach a list of the organization's Board of Directors or other individuals responsible for governance. Name of Medical Director: Attach a copy of the Medical Director's license and curriculum vitae. Executive Director (senior staff person responsible for running the organization if other than the Medical Director): Attach a copy of the Executive Director's current curriculum vitae or resume. Attach a copy of the eye bank's latest annual report or other documentation summarizing organizational performance and community benefit and any relevant public information materials (newsletter articles, brochures, etc.) Additional attachment: Additional attachment 2: Functions performed: If your eye bank performs other functions, please specify: Provide statistics for the previous year beginning on January 1 and ending on December 31. Count only those eyes/corneas recovered locally by your eye bank. Total number of eyes/corneas recovered by your eye bank: Number used for surgery: Number used for research/training: Number discarded: Please attach 1-3 letters of support and recommendation from related medical or health service organizations (e.g. local ophthalmologic society, US eye bank with which you have worked, etc.). Letter 2: Letter 3: Are you a member of any other professional organizations? If yes, please list: Please attach a letter signed by the eye bank's Board President (head of governing body); physician Medical Director and Executive Director (or head of staff) confirming the group's intent to pursue EBAA Membership: A $100 application fee must accompany all membership applications. This fee can be submitted via check payable to the Eye Bank Association of America, 1015 18th Street, NW, Suite 1010, Washington, DC 20036. Or follow this link to pay the membership application fee online. Applications received by April 1 are typically reviewed by the Constitution & Bylaws Committee and put forward to the Board of Director for approval in June. Applications received by September 1 are typically reviewed by the Constitution & Bylaws Committee and put forward to the Board of Director for approval in October or November (whenever the fall meeting is held). The Constitution & Bylaws Committee reserves the right to request additional information during its review process.
Please contact Molly Georgakis, Vice President, Member Services with any questions about EBAA Membership or the membership application process.
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