ENT Ear Nose and Throat
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Membership Application

THE SOUTH AFRICAN SOCIETY OF OTORHINOLARYNGOLOGY
APPLICATION FOR MEMBERSHIP

 

Title:
Initials: *
Surname: *
Home Address : *
  *
  *
Postal Address: *
  *
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Code: *
Telephone.(H): *
Telephone.(W): *
Fax: *
Cell phone No: *
E-mail: *
Qualifications:

Please choose type of membership bellow
Private Practice:
Full-Time Hospital Practice:
Registrar:
Other:
Specify if other:
Proposer
(current ENT Society member)
Name of next of kin
(not residing with you)
Home Address:
Code:
Telephone.(H):
Date of application:
 
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Return to: Dr S Ramjettan
P.O Box 50598
Musgrave
Durban
4000

Fax no: (031) 207 4886
Tel no: (031) 207 4885
E-mail: practice@surgeon.co.za
 

 

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