Georgia Society of Clinical Oncology - GASCO logo for print

Georgia Society of Clinical Oncology - GASCO

Membership Physician Form

Name:
Home Address:
Home Telephone: Home Fax:
Name of Practice:
Office Address:
Office Telephone: Office Fax:
E-mail Address:
Primary Specialty:
Medical Oncology Radiation Oncology
Gynecologic Oncology Surgical Oncology
Hematology Other
Georgia Medical
License Number:
Are you a member of the American
Society of Clinical Oncology (ASCO)?
Yes No
Please Check the appropriate category of membership:
Physician Member - Physicians whose major clinical interest is in the diagnosis and treatment of patients with neoplastic or hematologic diseases and are duly licensed to practice medicine in the state of Georgia. Annual dues are $25.00 ($10 for CPNG members) and member will have voting privileges.
Institutional Member - Physicians who are primarily affiliated with one of the academic medical institutions located in the state of Georgia and whose major clinical interest is in the teaching, diagnosis and treatment of neoplastic and hematologic diseases and are duly licensed to practice medicine in the state of Georgia. Annual dues are $25.00 ($10 for CPNG members) and member will have voting privileges.
Associate Membership - Medical school students, fellows and physicians-in-training who have an interest in the field of clinical oncology. Annual dues will be waived and member will not have voting privileges.

In order to complete the application process, the applicant must obtain the names of two (2) colleagues (preferably a current GASCO member) who will attest to the applicant's professional abilities and provide recommendation for membership in the Georgia Society of Clinical Oncology.

Colleague: Phone:
Colleague: Phone:
If your Curriculum Vitae is online, where may we review it (what is the URL)? www.
If your Curriculum Vitae is not online, please mail an updated copy of your Curriculum Vitae to the following address:
Georgia Society of Clinical Oncology
3330 Cumberland Boulevard, Suite 225
Atlanta, Georgia 30339