MEDITERRANEAN SOCIETY of OTOLOGY AND AUDIOLOGY
Proposal for Membership
1. Name: Wife Name:
2. Business Address:
Business Telephone: Business Fax:
Email Address ( If you dont have any email address,please enter only default@politzersociety.org) :
Home Address:
Home Telephone:
3. Date and Place of Birth:
4. Education: Name of School Dates attended: Degree & Date
5. Otolaryngological training - Dates
6. College teaching appointments - Dates
7. Membership in Medical Societies:
8. Practice limited to Otology: Yes No
9. Length of Otolaryngology Practice:
10. Date of Submission:
Note: Annual membership fee is 50 Euros including the subscription of the Mediterranean Journal of Otology.