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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. 

 

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, you will be able to pay the  application fee online. If you would rather pay with check, please mail check along with your CV to GNS, 6134 Poplar Bluff Circle, Suite 101, Norcross, GA  30092.

 

Terms and Conditions

6134 Poplar Bluff | Suite 101 | Norcross, GA 30092 | p. (770) 613-0932 | f. (305) 422-3327