Georgia Obstetrical & Gynecological Society Membership Application - 2008
Please print this page, complete and mail this application to the following address:
Make check payable to GOGS
GOGS
4485 Tench Road, Suite 2410
Suwanee, Georgia 30024
Please enclose this application with:
Dues: $100.00
Lobbyist support: $75.00
GynPAC (optional): $25.00
(Political Action Committee, which supports legislative
activities key to women’s heath.)
Total: $200.00
*Contributions for legislative activities are not tax deductible.
for questions:
Phone: 770.904.0719
Fax: 770.904.5251
(please print your information clearly)
Name: ___________________________________________________________________________
Spouse’s Name: _________________________________________________________________
Office Address:_____________________________________________________________________
City: _____________________________________________________ State: ____ Zip: ______
Phone: ______________________________________ Fax: ______________________________
E-mail: ___________________________________________________________________________
Primary Specialty:__________________________________________________________________
Medical License No: ________________________________________________________________
Residency: ________________________________________________ Years: _____________
Birth Date: ______________________________________________________________________
Home Phone: ____________________________________________________________________