Membership

November 26, 2010

INFECTIOUS DISEASES SOCIETY OF OHIO: YEARLY DUES PAYMENT

Please return this form with your payment to:

Michael F. Para, MD
Division of Infectious Disease
Ohio State University Medical Center
410 West 10th Ave, Room N1143,
Columbus, OH 43210

NAME: _________________________________________________________

ADDRESS: _______________________________________________________

_______________________________________________________________

_______________________________________________________________

PHONE: ________________________________________________________

FAX: __________________________________________________________

E-MAIL: _______________________________________________________

TYPE OF MEMBERSHIP:

______ Regular ($50.00/year)

______ Fellow-in-training ($25.00/year)