| SOUTH
BAY PATHOLOGY SOCIETY MEMBERSHIP APPLICATION return to: Gerald A. Weiss, M.D., membership chair Regional Medical Center Department of Pathology 225 N. Jackson Ave San Jose Ca. 95116 Fax 408-928-7048 |
Please attach a small photo
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NAME________________________________ BIRTHDATE______________________
MAILING ADDRESS______________________________________________________
_____________________________________________________________________
E-MAIL ADDRESS_______________________________________________________
BUSINESS PHONE( )_______________
HOME PHONE( )________________
[] CHECK IF OK TO POST E-MAIL ADDRESS ON
WEBSITE SOUTHBAYPATH.ORG IN MEMBER DIRECTORY
HOSPITAL/INSTITUTION_________________________________________________
____________________________________ DATES__________________________
AMERICAN BOARD CERTIFICATION:
ANAT. PATH___________ CLIN. PATH___________ OTHER_________________
LICENSURE___________________________
SPONSORS: 1. ________________________________________________________
________________________________________________________
2. ________________________________________________________
________________________________________________________
*PLEASE INCLUDE A CURRENT CURRICULUM VITAE
SIGNATURE_________________________________
DATE______________________
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FOR OFFICE USE
DATE RECEIVED______________________
ELIGIBLE AS OF_____________________
DATE ACCEPTED______________________ LETTER SENT__________________
APPROVAL BY MEMBERSHIP VOTE_________________
SIGNATURE OF MEMBERSHIP CHAIR____________________________________