RHINOLOGY AND SKULL BASE MINI-FELLOWSHIP PROGRAM

REGISTRATION FORM

Please send this form to us to be registered.

I am an Otorhinolaryngologist-Head and Neck Surgeon who would like to spend

___________(date start) until __________(date end) for the Rhinology and Skull
Base Mini Fellowship Program at the Dept of ORL-HNS, School of Medical
Sciences, Universiti Sains Malaysia, Malaysia. I understand while the program is
offered at no charge but I have to bear on my own the accommodation,living and
travelling costs.

Name: _____________________ Address: ________________________

Signature: __________________ ________________________

Phone: _____________________

Email:______________________