GSMA Membership Application

Personal Information

* Name (as it appears on your License)
* Name (as it should appear in GSMA directory)
* E-mail Address
Sex		Male Female
Date of Birth
Are you a U.S. citizen		Yes No
Are you a former member of Georgia State Medical Association, Inc.		Yes No
If yes, when		to
Office Address
Office Telephone
Office Fax
Preferred Address
Telephone/Cell Number

Medical Information

Medical School
Year Graduated
Specialty
Status		in active practice not in practice retired
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)		Yes No
		F/T Professor P/T Professor other
Are you in Government Service		Yes No
If yes, please list branch/rank/position
Are you a member of any other state and/or local society of the National Medical Association		Yes No
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