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New Member Registration

Please fill in the form below for your registration
The fields marked with * are mandatory.

First Name*:
Last Name*:
Father Name*:
Birthday Year*:
Speciality*: General Surgery
AggeioSurgery
NeuroSurgery
Plastic Surgery
Chest Surgery
CardioSurgery
Child Surgery
Other
University Title*: Professor
Lecturer
Assistant Professor
Substitute Professor
Graduation Year*:
Speciality Year*:
Medical Association*:
Medical Association No.*:
TSAY No.*:
Member Type*: Tactical member
Apprentice member
Associate member
Email:

Home Address:
Street/Number:
City:
PO Box:
Country:
Tel:
Fax:

Job Address*:
Job Place:
Position:
Street/Number:
City:
PO Box:
Country:
Tel:
Fax:

Contact me at: Home Address
Job Address

Member of other Associations: 1)
2)
3)

Desirable Username*:
Desirable Password*:
 
  
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