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.
