GSMA Membership Application FormPlease enable JavaScript in your browser to complete this form.Personal InformationName *FirstLastName (as it appears on your License) Name *FirstLastName (as it should appear in GSMA directory) Email *GenderFemaleMaleOtherSelect OneDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you a U.S. citizenYesNoPermanent ResidentJ1-VisaAre you a former member of Georgia State Medical Association, Inc.?YesNoBegin DateStart of GSMA Membership DateEnd DateEnd of Prior GSMA Membership DateOffice AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneMobile PhonePreferred Mailing AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMedical InformationMedical or Podiatric SchoolYear Graduated SpecialtyWork StatusActive Clinical PracticeAcademicAdminstrativeResearchNot in practiceRetiredAre you on the faculty/administration of a medical school (or other institution)F/T ProfessorP/T ProfessorOtherBoard CertifiedYesNoEligibleState Medical Licensures and NumbersState Medical Licensures and NumbersState Medical Licensures and NumbersDegrees other than M.D.PhDMBAMPHJDPlease list any health maintenance organizations with which you are affiliatedPlease list any health maintenance organizations with which you are affiliatedPlease list any health maintenance organizations with which you are affiliatedPlease list any health maintenance organizations with which you are affiliatedOther InformationAre you in Government Service?YesNoAre you a member of any other state and/or local society of the National Medical AssociationYesNoPlease list branch/rank/positionGovernment Service Branch, Rank and TitleList State SocietyNMA AffiliateList Local SocietyNMA AffiliateSpouse/Partner/Cohabitor NameSpouse/Partner/Cohabitor OccupationOccupationPlease list any special interests and/or activities you would like to be involved in with or on behalf of the Georgia State Medical Association MessageSubmit