Name and Degree (e.g. MD, PhD)
Faculty Title (e.g. Clinical Associate Professor)
Office Telephone Number
I am a member of the (please check one)
Full Time Faculty Part Time Faculty Voluntary Faculty
Yearly membership dues are $50 for faculty with annual salaries equal to or greater than $60,600 and $25 for faculty with annual salaries less than $60,000.
Enclosed is my check for my membership dues in the amount of $_________________ made payable to Mount Sinai Fund #0244-1160.
Please print out this membership form and send together with your check to:
Dr. Sandra K Masur.
Department of Ophthalmology