Humanitarian Membership Application for medical staff in the Ukraine

The OTA is offering temporary free membership to the OTA for the purpose of online orthopaedic content, access to the Online Discussion Forum to request help from other OTA members, and other members-only content from the OTA. If you are interested in this membership, please complete the questions below.

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* 1. First Name:

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* 2. Last Name:

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* 3. Degree

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* 4. Preferred Email Address:

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* 5. Please enter your preferred mailing address:

Home

Work

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* 6. Company/Institution Name:

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* 7. Street Address (for Home or Office selected in Question #4)

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* 8. City:

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* 9. State or Province:

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* 10. Postal Code:

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* 11. Country:

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* 12. Perferred phone number (with country code):

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* 13. Please upload a headshot for your profile:

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