SSAC membership application form

Print the application form on the nearest printer, complete the form and mail or fax it to the current general secretary.

Name:                                                                                                                                                                                
MD (  )Yes  (  ) No 
Specialty (  ) Infectious Diseases (  )  Clinical microbiology (  ) Other............................................................................ 
Under education If you are still under education, state intended specialty (line above) and the probable year: ...................
Highest degree:    
Current position:    
Adress: Professional: 
   
Home: 
 
Telephone: Professional:
 Home:  
Fax    
Email :    

Interest in antimicrobial chemotherapy (summarize your activities in the field and if not MD list pertinent publications):






Application  date _________________________Signature___________________________________________