Membership Application


You may register and pay dues online via credit card by clicking here, or printing and filling out the application below.

Please either
click here to download the application as a pdf document  (Adobe Acrobat Reader required) or you can print this page and fill in the information below.  You can fax/mail as detailed below.  Please submit the application along with your dues.

We are a 501(c)3 organization.  Dues are tax deductible.


PA Neurological Society - Membership Application


Full Name (Last First Middle) MD / DO __________________________________________________________

Office/Clinic Name ____________________________________________________________

Office Address ____________________________________________________________

____________________________________________________________

City, State ____________________________________________________

Zip_________________________________________________________

Phone ______________________Fax _____________________________


Please place an "X" here: ____ if you do not want your name and office

information available online.


Residence Address
____________________________________________________________

City, State ___________________________________________________

Zip ________________________________________________________

Home phone ________________________________________________

Cell phone: _________________________________________________

Email_______________________________________________________

Gender __________ Date of Birth ________________________________

Birth place__________________________________________________

Medical School (include location) __________________________________________________________

Dates _____________________________________________________

Internship ____________________________   Dates _______________

Residency ____________________________ Dates ________________

Fellowship____________________________ Dates ________________

Professional Memberships:

  ____________________________________________________________

   ____________________________________________________________

   _____________________________________________________________

Pennsylvania State License Number ________________________________

Date Issued ___________________________________________________


Preferred Method to receive correspondence:

(  ) email     (  ) fax     (  ) postal service                   

 (  ) Credit Card or (  ) $0 check payable to “Pennsylvania Neurological Society”

             If credit card:         (  ) MasterCard                     (  ) Visa        
               
Card Number: ____________________________________________

Expiration Date: ___________________________________________ 

I hereby apply for membership in the PNS, submitted my $50 dues (residents/fellows free), and agree to abide by its Bylaws and the Principles of Medical Ethics.  In consideration of the PNS processing my application for membership, I grant permission and consent for their obtaining verification of the above information.

Signature: _______________________________________________

Date:          _______________________________________________


Send application (and check if applicable) to: Attn: Jackie
DeWitt,        
Pennsylvania Neurological Society,
Central Medical Arts Bldg., 433 Frye 
Farm Road, Greensburg, Pennsylvania 15601.

Please direct any questions to: Contact Jackie Dewitt: (724) 537-0885 x119.

You may fax your completed application to Jackie Dewitt:  (724) 805-0084.

 

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