GSMA Membership Application

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


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