Georgia Orthopaedic Society | Member Application

Membership Application
You must be a graduate of an approved Orthopaedic Surgery Residency Program and certified by the
American Board of Orthopaedic Surgery (ABOS) or the American Osteopathic Board of Orthopaedic
Surgery (AOBOS) and maintains good standing in the AAOS or AOBOS.

To apply online, please fill out the form below.
Membership Application is due on August 1st 2010.

*Denotes required field.

*Applicant's Name:

*Date of Birth:

*Office Address:

*City:

*State:

*Zip:

*Office Phone:

Office Fax:

*Email:

*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 practice in the state of Georgia since

*Medical Association of Georgia Member?
(though not a requirement, membership
and participation in MAG is encouraged)

Yes

*Certified by American Board of Orthopaedic Surgery or American Osteopathic Board of Orthopaedic Surgery?

Yes -- Date Certified

*Candidate for Certification By American Board of Orthopaedic Surgery or American Osteopathic Board of Orthopaedic Surgery?

Yes

I promise to abide by the Principles of Medical Ethics as established by
the American Medical Asssociation.
*DATE SUBMITTED:

I authorize review of this information. (required)

** Resident Membership Application Click Here **

* Please provide supplemental information below:
Copy of Georgia License
Copy of Board Certification (if applicable)

Mail or fax to:
LIZ NEARY
EXECUTIVE DIRECTOR
131 Holly Springs Drive
Peachtree City, GA 30269
FAX: 678-669-2754
lnearygos@gmail.com