MAES/OHNS Address Update Form

Name:_____________________________________________________________________

Street Address:______________________________________________________________

City, State, Zip: ______________________________________________________________

Office Phone:____________________________

Office Fax:______________________________

Email:_____________________________ (We plan on email only for future correspondence.)

Website:_________________________________ (To be hyper linked on the MAES website)

[   ] I would like to pay my yearly dues of $175 and pay for dinners in advance (pays for all 5 dinners) for a total of $325 (a $100 savings!)

[   ] I would like to pay my yearly dues of $175 now and pay for individual dinners throughout the year at $50 per dinner.

Please make checks payable to:

Metro Atlanta Educational Society for Otolaryngology - Head and Neck Surgery or MAES/OHNS Society

Please return to:

Metro Atlanta Educational Society
P.O. Box 11648
Atlanta, GA 30355
Phone: 404-257-1589
Fax: 404-303-1950