GSMA Membership Application

Personal Information
* Name (as it appears on your License)
* Name (as it should appear in GSMA directory)
* E-mail Address
Date of Birth
Are you a U.S. citizen
Are you a former member of Georgia State Medical Association, Inc.
If yes, when
 Office Address
Office Telephone
Office Fax
Preferred Address
Telephone/Cell Number
Medical Information
Medical School
Year Graduated

Board Certificate
State Medical Licensures and Numbers
Degrees other than M.D.
Please list any health maintenance organizations with which you are affiliated
Other Information
Are you  on the faculty/administration of a medical school (or other institution)
    F/T Professor P/T Professor other
Are you in Government Service
If yes, please list branch/rank/position
Are you a member of any other state and/or local society of the National Medical Association
If yes, please list
  local    state
List any other medical society affiliations
Spouse's Name
Spouse's Occupation
Please list any special interests and/or activities you would like to be involved in with
or on behalf of the Georgia State Medical Association