Page 64 - World Journal of Laparoscopic Surgery

APPLICATION FOR MEMBERSHIP OF WORLD ASSOCIATION OF LAPAROSCOPIC SURGEONS

WALS
International Organization for Promotion of Laparoscopic Surgery among Surgeons and Gynecologists

1. APPLICANT INFORMATION 2. EDUCATION
Please fill this form in Block Letters. Institute Degree and date awarded
First Name: Graduation:
Middle Name: Postgraduation:
Last Name: MAS training:
e-mail:
3. MEDICAL LICENSURE
Date of Birth:
Licensed to practice Registration
Place of Birth: medicine in which country: number

Which address below should WALS use as your primary
contact address?
Has your medical license ever been Yes
Professional suspended or revoked in any state? No
Residential
Have your privileges ever been Yes
suspended or changed? No
Professional address
Institution: 4. TRAINING
Department:
Was laparoscopy included in
Mailing address: your residency or fellowship training?
City: Did you receive the training from a Yes
State or Province: Postal Code: course or program? Please indicate
and specify location and date.
Country: Phone:
Course and Program Instructor:
Residential address
Residential address 1: 5. SIGNATURE
Residential address 2: I authorize the World Association of Laparoscopic
City: State or Province: Surgeons to obtain information from societies, hospital
staffs, members, and any other source regarding this
Postal code: Country: application and my qualifications for membership, which
Phone: Fax: information will be kept confidential by the Society.

Please send the completed application form to any of the nearest office of
WORLD ASSOCIATION OF LAPAROSCOPIC SURGEONS:
Mailing Address
UNITED STATES OF AMERICA EUROPE INDIA
2874 West Lakeshore 39 Brush Field Way Laparoscopy Hospital
Dr Tallahassee Knaphill 8/10 Tilak Nagar, New Delhi, India
Florida 32312, United State Woking Tel: +91(0)11- 25155202, 42138116
e-mail: usa@wals.org.uk Post Code: GU21 2TQ e-mail: india@wals.org.uk
Alternative e-mail: e-mail: uk@wals.org.uk Alternative e-mail:contact@laparoscopyhospital.com
Laparoscopy2001@yahoo.com Tel: +91(0)11- 25155202, 42138116
IRAN AFRICA KINGDOM OF SAUDI ARABIA
Haftom Tir Medical Center Gulu Independent Hospital Dept of General, Laparoscopy
Tehran, Iran Airfield Road, PO Box 23 and Endocrine surgery
Tel: ++9821-841 3375 Gulu Northern Uganda King Fahad Hospital Medina KSA
Fax: ++9821-841 3378 Tel: +256-47132279 Mailing Address:
e-mail:apazouki@yahoo.com/paz Fax: +256-41348334 PO Box; 5147 Medina Munawarah, KSA
ouki@iums.ac.ir e-mail: guluindp@aol.com e-mail: fiazmfazili@yahoo.com