Greek OrthoWeb

my current address is :____________________________________________________________

MD:____ MD,PhD:____PhD:____EXHIBITOR :____ ACCOMP. PERSON:____

First Name : __________________________Middle Initial:__________Family Name :_________________

Affiliation :__________________________________________________Position:______________________

srt:__________________________________________City :________________________________________

Zip Code :___________________________State :_________________________Country :______________

Phone :______________________________________________ FAX:________________________________

Member of EFSM :________, IMS :_______,ASPN :_______,ASRM :_______,HSRM :_____,HSSH :_____

Other Society :_______

I want to : Partecipate :______,Present :_____,Exhibit Poster :_____Submitt a video :________

Accompanying members:_______________

Extend my stay for vacation :_______________________

PRINT AND RETURN IT TO :

H.S.R.M. c/o K.N. MALIZOS,MD

20 FLEMING STR.,GR 151 23 MAROUSSI

ATHENS - GREECE

TEL :+30 1 68 57 836 FAX: +30 1 68 57 838