WIO Chapter Annual Report

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* 1. Chapter Information

Chapter Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

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* 2. Meeting Report - Please provide information on any chapter events held during the 2014 calendar year

Date:

Attendance:

Summary:

Financial Support:

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* 3. Membership Report – Please complete the grid below and send a membership roster to info@wioonline.org.

Member (MD, PhD, DO)

Associate (non MD, PhD, DO)

Member-in-Training (Resident/Fellow)

Medical Student

Retired

Total Membership

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* 4. Other Activities – Please inform us of any other activities you conducted throughout the year.