| Last Name:____________________
First Name:___________________ Middle Name:_____________
Designation:_______________________________________________________________________
Institution:_________________________
Medical Specialty:__________________________________
DOB:__________________________
Male:_______
Female:
______
Business Address: (I would like
all mail to go to my business address. Yes_____
No ____)
_________________________________________________________________________________
_________________________________________________________________________________
City State Zip
_________________________________________________________________________________
Providence Country Postal code
Telephone________________________Fax:_________________
E-mail address:_______________
Home Address: ( would like
all mail to go to my home address. Yes_____ No
_____)
_________________________________________________________________________________
_________________________________________________________________________________
City State Zip
_________________________________________________________________________________
Providence Country Postal code
Telephone________________________Fax:_________________
E-mail address:_______________
My future contribution to the
EEMS and my community:
I want to make a presentation
to EEMS members on the following topic:_________________________
I want to organize a workshop on the following
topic:________________________________________
I want to lead the community based program for
Eastern European Medical Community: ________________________________________________________________________________
I want to make a charitable, tax deductible donation
to EEMS.
I want to write an article on the following topic:_____________________________________________
Ethical Declaration:
(Please check one of the following:)
I hereby warrant that:
______ There have been no instance
of determination by government entity that I have
violated the law and no instance of determination
by private body or government entity that I have
violated provisional medical ethics in any county
including United States of America.
______ Affirmation of completion
and accuracy. I confirm that the information on
this application is complete and accurate to the
best of my knowledge.
______________________________________
___________________________
Signature Date
|
