APPLICANT _________________________________________________________________________

                            Last Name                             First Name                          MI

Mailing Address (Membership materials will be mailed to this address)__________________________

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Country___________________

Postal Code:___________

Fax:____________

Phone: Office_______________

Home (Optional)________

Email:__________

Degrees (MD, PhD, etc.)______________________________________________________________

Title ______________________________________________________________

Academic or Institution Affiliation and address (if different from above)_______________________

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Laser Experience and Types of Laser Used_______________________________________________

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Areas of Interest ____________________________________________________________________

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References ________________   

1) Name ________________

2) Name ______________

Address_________________

Address_______________

Enclosed US $ 100 application fee (Demand Draft) payable to "ISLSM, HSBC Chennai". I have read and agree to abide by the Bylaws of the ISLSM insofar as they affect me.

President :
Prof. B; Krishna Rau.
HOD of surgery
Director of Gasteroentology
Sri Ramachandra Medical College and Research Institute 
No.9, (5) Chandra Bagh Avenue, 
Second Street, Mylapore,
Chennai - 600 004. Tamil Nadu, India.
Hospital : Tel : 4765856, 
Fax: 0091 44 8594578
E-mail : bkr@vsnl.com
krishnarau@hotmail.com 

Secretary General :
prof. Toshio Ohshiro.
Director of Japan Medical Laser Lab
Hachiko Bldg. 4F, 4-4-1, Ginza, chuo-ku,
Tokyo 104-0061, JAPAN
Tel : 81-3-3563-1403
Fax : 81-3-3563-1401
Email : Ohgin@magical3.egg.or.jp 

Treasurer
Prof. Gerald J. Glantz MD FACS
West Los Angeles,
VA Medical Centre, 
Dept of Surgery,
W112, 11301, Wilshire Blvd,
Los Angeles, California 90073, USA
Tel :310 2683075
Fax : 310 2684967
Email : gglantz@ucla.edu