THE POLITZER SOCIETY
Proposal for Membership
Candidates for membership in the Politzer Society must be proposed and seconded by members of the Society.
Letters from both Proposer and Seconder ARE NECESSARY in order to permit consideration of the application.
A member desiring to propose a candidate will furnish the following biographical data of the prospective member.
1. Name: Wife Name:
2. Business Address:
Business Telephone: Business Fax:
Email Address ( If you dont have any email address,please enter only default@politzersociety.org) :
Home Address:
Home Telephone:
3. Date and Place of Birth:
4. Education: Name of School Dates attended: Degree & Date
5. Otolaryngological training - Dates
6. College teaching appointments - Dates
7. Membership in Medical Societies:
8. Practice limited to Otology: Yes No
9. Length of Otolaryngology Practice:
10. Attach articles or papers published and a scanned photograph within your e-mail to: ozgirgin@politzersociety.org.
11. Names of Proposer and Seconder:
12. Date of Submission:
13. Security Code: