Georgia Society of Clinical Oncology - GASCO logo for print

Georgia Society of Clinical Oncology - GASCO

Administrator Membership Form

Name:
Title:
Phone: Fax:
E-mail Address:
Practice Name:
Home Address:
City: County:
State: Zip Code:
Please list the names of all of the physicians in your practice. (Please place an asterisk by those
which are GASCO members)
Please check the best description of your employer:
Private Hematology/Oncology Practice
Radiation Oncology
Academic-based Hematology/Oncology
Other
Would you be interested in volunteering
to help with this organization?
Yes No
Practice Manager/Administrator Member - membership is $25 (One or more physicians must be a GASCO member) - Voting privileges limited to matters of the Administrators Association.
Administrative Affiliate - membership is $25 - Administrative/non-clinical personnel (Management/Administrator must already be a GASCO member).