Name and Degree (e.g. MD, PhD)

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Department

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I am a member of the (please check one)
Full Time Faculty   Part Time Faculty   Voluntary Faculty

Professional Interest

Yearly membership dues are $50 for faculty with annual salaries equal to or greater than $60,600 and $25 for faculty with annual salaries less than $60,000.

Enclosed is my check for my membership dues in the amount of $_________________ made payable to Mount Sinai Fund #0244-1160.

Please print out this membership form and send together with your check to:
Dr. Sandra K Masur.
Department of Ophthalmology
Box 1183