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MAES/OHNS Membership Form

Please print form, complete & return to the Treasurer
at the address below.

Name:_____________________________________________________________________

Street Address:______________________________________________________________

City, State, Zip: ______________________________________________________________

Office Phone:____________________________

Office Fax:______________________________

Email:_____________________________ (We plan on email only for future correspondence.)

Website:_________________________________ (To be hyper linked on the MAES website)

[   ] I would like to pay my yearly dues of $400 and pay for dinners in advance (pays for all 4 dinners).

Please make checks payable to:

Metro Atlanta Educational Society for Otolaryngology - Head and Neck Surgery or MAES/OHNS Society

Please return to:

MAES
Joshua M Levy, MD, MPH
Assistant Professor, Emory University, Dpt of Otolaryngology Head & Neck Surgery
Emory Sinus, Nasal & Allergy Center
550 Peachtree Street, NE
Atlanta, GA 30308


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