Information Request Form | WDS Academic Dermatologist Interest Group

WDS Academic Derm Interest Group Home • Breakfast Meetings 2008| 2007|2006 • Academic Research Grant Program • Info Request Form • Group eMail

WOMEN’S DERMATOLOGIC SOCIETY
WDS Academic Dermatologist Interest Group Request Form

REQUEST FORM DATE:--

Full Name:

Academic Institution:

Degree or Title:

Spouse Name:

Preferred Mailing Address:

Address 1:

Address 2:

City:

State:

Zip:

Country:

Office Phone:

Fax Number:

eMail:

Academic Track
(Check all that apply)

Tenured
Non-Tenured
Researcher
Clinician
Educator
Still in Training

If in training, what is your expected completion date?

Areas of Interest:
(Check all that apply)

General Dermatology
Pediatric Dermatology
Genital Dermatology
Dermatopathology
Medical Dermatology
Contact Dermatology
Melanoma
Ethnic Skin
Hair/Nails
Acne
Other:

Would you like to be included in an Academic Dermatologist eMail ListServe?

Yes
No

Would you like your information to be made available in a Academic Dermatologist section on the WDS website?

Yes, allowing the email address on the website for Members-Only (public will not have access to eMail)
Yes, but do not provide e-mail address
No

Would you allow the printing of your information in the printed WDS Directory for members?

Yes, including my email address
Yes, without my email address
No, to any information being placed in the printed membership directory

ADDITIONAL COMMENTS:

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