Georgia State Medical Association, Inc.



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Information:
* Name (as it appear on diploma)
* Name (as it should appear in GSMA directory)
* E-mail Address
Sex	Male Female
Date of Birth
Are you a U.S. citizen	Yes No
Are you a former member of Georgia State Medical Association, Inc.	Yes No
If yes, when	to
Office Address
Office Telephone
Office Fax
Home Address
Home Telephone
Home Fax
Medical Information:
Medical School
Year Graduated
Specialty
Status	in active practice not in practice retired
Board Certificate
State Medical Licensures and Numbers


Degrees other than M.D.
Please list any health maintenance organizations with which you are affiliated





Other Info :
Are you on the faculty/administration of a medical school (or other institution)	Yes No
	F/T Professor P/T Professor other
Are you in Government Service	Yes No
If yes, please list branch/rank/position
Are you a member of any other state and/or local society of the National Medical Association	Yes No
If yes, please list	local state
Are you a member of state and/or local society of the American Medical Association	Yes No
If yes, please list	local state
List any other medical society affiliations
Spouse's Name
Spouse's 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

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