South Carolina Society for Allergy, Asthma & Immunology

APPLICATION FOR MEMBERSHIP

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NAME

PERMANENT ADDRESS

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Address Line 2

City

State

Zip Code

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TELEPHONE

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COLLEGE/DEGREE

YEAR OF GRADUATION

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MEDICAL SCHOOL

YEAR OF GRADUATION

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RESIDENCY

YEARS

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ALLERGY FELLOWSHIP

YEARS

TEACHING POSITIONS

BOARD CERTIFICATION/ELIGIBILITY

YEARS IN PRACTICE

APPROXIMATELY WHAT PERCENTAGE OF YOUR PRACTICE IS ALLERGY

LICENSED IN WHAT STATES

MEMBER OF WHAT ASSOCIATIONS

OTHERS

HOSPITAL AFFILIATIONS

RECOMMENDED BY: NAME OF ACTIVE AAISSC MEMBER

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DATE

SIGNATURE

PLEASE INCLUDE A CURRENT COPY OF YOUR CV

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APPLICATION FEE

Price: $ 100.00

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Card

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