GSMA Membership Application Form

Personal Information

Name
Name (as it appears on your License)
Name
Name (as it should appear in GSMA directory)
Gender
Select One
Date of Birth
Are you a U.S. citizen
Are you a former member of Georgia State Medical Association, Inc.?
Office Address
Transactional Messaging
By checking this box and submitting this form, you consent to receive transactional text messages for Membership Dues, Convention Registration, Donation Requests from GSMA. Reply STOP to opt out. Reply HELP for help. Standard message and data rates may apply. Message frequency may vary.
SMS Consent
By checking this box and clicking “SUBMIT” you consent to receive text messages for marketing from GSMA. Reply STOP to opt out. Reply HELP for help. Message and data rates may apply. Message frequency may vary.
Terms, Condition and Privacy Consent
I agree to the Terms and Conditions of GSMA Constitution & ByLaws 2024 and GSMA Privacy Policy!
Preferred Mailing Address

Medical Information

Work Status
Board Certified
Degrees other than M.D.; D.O.

Other Information

Are you in Government Service?
Are you a member of any other state and/or local society of the National Medical Association
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