GSMA Membership Application – GSMA Next Millennium Site

Personal Information

Name *

First

Last

Name (as it appears on your License)

Name *

First

Last

Name (as it should appear in GSMA directory)

Email *

Gender

Female
Male
Other

Select One

Date of Birth *

Are you a U.S. citizen

Yes
No
Permanent Resident
J1-Visa

Are you a former member of Georgia State Medical Association, Inc.?

Yes
No

Begin Date

Start of GSMA Membership Date

End Date

End of Prior GSMA Membership Date

Office Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Mobile Phone

Preferred Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Medical Information

Medical or Podiatric School

Year Graduated

Specialty

Work Status

Are you on the faculty/administration of a medical school (or other institution)

F/T Professor
P/T Professor
Other

Board Certified

Yes
No
Eligible

State Medical Licensures and Numbers

Degrees other than M.D.

PhD
MBA
MPH
JD

Please list any health maintenance organizations with which you are affiliated

Other Information

Are you in Government Service?

Yes
No

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

Yes
No

Please list branch/rank/position

Government Service Branch, Rank and Title

List State Society

NMA Affiliate

List Local Society

NMA Affiliate

Spouse/Partner/Cohabitor Name

Spouse/Partner/Cohabitor Occupation

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