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 Membership Form

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 The Asian-African Society of Mycobacteriology (2016-2017)

Family Name………………………

 Name: ………………………………..

Gender: M□  F□

Date of Birth: └┴┴┴┴┴┴┴┘ 

Degrees:

□ M.D Specialty:

□ Ph.D

□ M.Sc

□Others


Date: ………………. 

Signature:

 

 


 

 
If you wish to receive the hard -copy of  International Journal of Mycobacteriology( for free ) please fill the below section completely :

Postal Address:




Country:

City:

Zip code:

Phone:

Fax:

Email:

Position:

□ Scientific Board

□ Clinical 

□ Research Center

□ University

 

Please complete this form and return directly by email to : farnia@theaasm.org