Georgia Orthopaedic Society

GEORGIA ORTHOPAEDIC SOCIETY MEMBERSHIP APPLICATION

With your application, please forward your $200.00 check after completing this form.

___ Three letters of recommendation requested

___ $200.00 application fee

___ Copy of Georgia License

___ Copy of Board Certification (if applicable)

___ Complete application form with signature

I have attended the annual meeting in (year) or will plan to attend in (year). (not a requirement)

If the appropriate requirements have been fulfilled, you will be voted upon at the annual meeting in October.

APPLICATION FOR MEMBERSHIP

APPLICANT'S NAME

DATE OF BIRTH (MMDDYY)

OFFICE ADDRESS

City

State

Zip

OFFICE PHONE

OFFICE FAX

OFFICE E-MAIL

SPOUSE'S FIRST NAME

HOME ADDRESS

City

State

Zip

HOME PHONE

SPECIAL PROFESSIONAL INTEREST
MEDICAL SCHOOL
DATE OF GRADUATION
RESIDENCY PROGRAM
DATE OF COMPLETION
FELLOWSHIP TRAINING (IF APPLICABLE)

GEORGIA LICENSE #	Date:
HAVE PRACTICED IN THE STATE OF GEORGIA SINCE
MEDICAL ASSOCIATION OF GEORGIA MEMBER (though not a requirement, membership and participation in MAG is encouraged)		YES NO
CERTIFIED BY AMERICAN BOARD OF ORTHOPAEDIC SURGERY ?
YES -- DATE CERTIFIED		NO
CANDIDATE FOR CERTIFICATION BY AMERICAN BOARD OF ORTHOPAEDIC SURGERY		YES NO

PLEASE LIST THREE ORTHOPAEDIC SURGEONS FROM WHOM YOU HAVE REQUESTED LETTERS OF RECOMMENDATION *(They must be members of The Georgia Orthopaedic Society)*
NAME:
NAME:
NAME:
I promise to abide by the Principles of Medical Ethics as established by the American Medical Association. DATE SUBMITTED: I authorize review of this information.[Required] SIGNATURE - *TO BE SENT WITH SUPPLEMENTAL INFORMATION* PLEASE MAIL SUPPLEMENTAL INFORMATION TO: LIZ NEARY EXECUTIVE DIRECTOR 186 Lake View Drive North Macon, Ga. 31210 478-474-2754 LizGOS@cox.net