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MEMBERSHIP APPLICATION

PEDIATRIC SOCIETY OF QUEENS INC.

NAME: _________________________________DATE: __ / __ / ____

ADDRESS: _______________________________TEL: ( ___ ) _______

DATE OF BIRTH: __ / __ /____ PLACE:_______________________________

EMAIL: ______________________________

EDUCATION: COLLEGE: _____________________________________________

DEGREE AND YEAR OF GRADUATION: _______________________________

MEDICAL SCHOOL: _________________________________________________

INTERNSHIP: _______________________________________________________

RESIDENCIES: ______________________________________________________

FELLOWSHIPS: ____________________________________________________

HOSPITAL APPOINTMENT DATES: __________________________________

LICENTIATE OF AMERICAN ACADEMY OF PEDIATRICS:

YES ___DATE: ___________________ NO _____

FELLOW AMERICAN ACADEMY OF PEDIATRICS:

YES ___DATE: ___________________ NO _____

HONORS: _____________________________________________________________________________________________________________

PUBLICATIONS: 

___________________________________________________

___________________________________________________

SPONSORS: 1._____________________________________________________

2. _____________________________________________________

PLEASE SEND THIS APPLICATION TO:

NATASHA SHAPIRO MD - MEMBERSHIP CHAIRPERSON

Tel # 347-393-1340 email: nas9132@nyp.org



ELECTION TO MEMBERSHIP: YES ____ NO ____ (Executive Committee Determination)

 

YOU WILL BE CONTACTED BY THE MEMBERSHIP CHAIRPERSON UPON RECEIPT AND ACCEPTANCE OF YOUR APPLICATION