GASCO Membership information
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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 $275.00 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 $275.00 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.
 
Name #1 Phone #
Name #2 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