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Institute Director
Professor Marcus Atlas
Patrons
Clinical Professor Barry J. Marshall AC
Nobel Laureate
Professor Alan Robson AM
Vice-Chancellor, UWA
Mr Vernon Wheatley
Former Director, AHG
Campaign Chairman
Mr George Jones
Chairman, Gindalbie Metals Ltd
Planning Committee Chairman
Mrs Debbie Schaffer
Leadership Gifts Committee Chairman
Mr Tony Adcock
Director, Red Pill Performance Consultants
Treasurer
Mr Frank Cooper
Partner, PricewaterhouseCoopers
DONATION REGISTRATION DETAILS.
The Ear Science Institute Australia (ESIA) has the vision to bring hope and relief to those who suffer ear, hearing and balance disorders.
The work of its world-leading specialist research and clinical teams is already yielding groundbreaking medical advancements that are enhancing and improving lives.
The establishment of a new research facility is key to ESIA's ability to forge ahead. A site has been acquired in Subiaco, and this major fundraising project is seeking to raise the capital for a dedicated building. With your much needed and valued help, it will bring under one roof the skills and expertise of a team of leading specialists, surgeons, researchers, clinicians, technologists and students.
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