Georgia Society of Clinical Oncology - GASCO logo for print

Georgia Society of Clinical Oncology - GASCO

Affiliation Member Application 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
Hospital-based Hematology/Oncology
Academic-based Hematology/Oncology
Other
Would you be interested in volunteering
to help with this organization?
Yes No
Affiliate Member - Membership is $25 ($10 for CPNG members).
Professionals that directly practice in oncology provider environments; including, but not limited to scientists, researchers, registered nurses, pharmacists, clinical administrators, social workers, case workers and mid-level providers.
No Voting Rights