Membership Application form 2018      


Personal Details
Date of birth
Work Location
 




Specializations:
Pediatric Surgery Urology

Request

ASK
to be admitted to the Italian Society of Pediatric Urology (SIUP)

Date Signature
21 - 08 - 2018 ______________________________
Permissions

We will treat your data in accordance with the Italian legislation.

Date Signature
21 - 08 - 2018 ______________________________

Il modulo deve essere spedito per posta o inviato per fax

al numero (0113135540) al:
Dssa Tadini Barbara
Urologia Pediatrica
Azienda Ospedaliera O.I.R.M.- S.ANNA PIAZZA POLONIA 94 - 10126 TORINO

info: Tel. 0113131827 - Fax 0113135540