Georgia Society of Otolaryngology / Head & Neck
Surgery
APPLICATION FOR MEMBERSHIP
If you
are not currently a member of the Georgia Society of Otolaryngology/Head &
Neck Surgery, we would
like to take this opportunity to invite you to join your state specialty
organization. Membership dues are $75 per year.
Name Req.
Practice Name
Office Address
City, State Zip
E-mail Req.
Phone
Mobile
Fax
Date of Birth
Place of Birth
Please list the
name of two GSO/HNS members we can contact for a reference:
You may
send in a copy of your CV OR fill in the following:
Training to
include Colleges, Degrees, Internships, Residencies, Post Graduate
Training, Special Training in Otolaryngology (dates in chronological
order):
Present
appointments - hospital and teaching:
Scientific and
Professional Societies:
Date of
Beginning Exclusive Practice of Otolaryngology in the State of Georgia:
Date of
Certification from American Board of Otolaryngology:
After
submitting this form, mail the $75 application fee to GSO/HNS, 6134
Poplar Bluff Circle, Suite 101, Norcross, GA 30092.
