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Application for Membership

If you are not currently a member of the Georgia Neurosurgical Society, we would like to take this opportunity to invite you to join your state specialty organization.

First Name A value is required.
Last Name A value is required.
Credentials A value is required.
Mobile Phone A value is required.
Email A value is required.Invalid format.
Birthday mm/dd/yy A value is required.Invalid format.

Work Contact Information
Practice Name
Address 1 A value is required.
Address 2
City A value is required. State A value is required. Zip A value is required.
Work Phone A value is required. Work Fax
Website

Home Contact Information
Address 1
Address 2
City State Zip

History
Medical School A value is required.
Year of Graduation A value is required.Invalid format.Minimum number of characters not met.Exceeded maximum number of characters.
Residency A value is required.
Year A value is required.

References - Please list the name, address, and phone number of two recommending GNS members
A value is required.

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.