HSIOIRS Membership Application

Name*

Surname*

Office Address*

Home Address*

Date of birth*

Institution

Title / Position in*
PrivatePublic Health SystemUniversityRetired

Office Telephone*

Mobile*

Email*

Year of Completion of Residency*

Are you a surgeon?*
Anterior SegmentPosterior SegmentI’m not a surgeon

Do you perform refractive surgeries?*
YesNo

Curriculum Vitae

Brief CV*

Reference from two HSIOIRS members

Terms and Conditions*
«I agree that the information I provide through this website is collected and processed by HSIOIRS for communication and information purposes in accordance with the terms and conditions of use. I understand that I have the right to withdraw my consent at any time and that I have the right to access, correct and delete my data».