KOPANA membership application 
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Email *
Optional--Alternative email address (if in training, please provide a personal email address, if possible)
I am completing this form in order to: *
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Last name (family name) *
First name (given name)  *
Institution of employment (if retired, last institution of employment) *
Preferred mailing address
Country *
Your position in practice *
If trainee: resident or fellow? Please enter the expected year of completing the residency/fellowship training. 
Please select your subspecialty--you may select multiple options (if in training, subspecialty of interest/training)
These additional questions below are optional questions that are included for planning future KOPANA events. 

Are you interested in being invited to give presentations at future KOPANA seminars? 
Clear selection
If "Yes" to the previous question, which areas are you interested in giving presentations in? 
If you were to give presentations for KOPANA, would you feel comfortable giving the talk in English? 
Clear selection
Which topics would you suggest for future KOPANA seminars? 
New members: We would appreciate your contribution to KOPANA through the membership fee of $50 (the fee is waived for students and trainees). Please use this Paypal link for membership fee payment and check the box below.
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Any comment or requests?
A copy of your responses will be emailed to the address you provided.
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