NORTH CAROLINA SOCIETY OF
Application for Membership
Complete this form or join online at join (select “specialty societies” from the drop down menu)
Section I
|Full Name: | |Credentials: | MD, DO, | |
| Male | Female |Date of Birth: | |Married? Yes |Spouse’s Name | |
|Email: | |Cell Phone: | |
|Practice Name: | |Fax Number: | |
|Business Address (preferred mailing address? Yes): | |City, State, Zip: | |Business Telephone: |
| | | | | |
|Home Address (preferred mailing address? Yes): | |City, State, Zip: | |Home Telephone: |
| | | | | |
Section II
|Medical School: | |Year of Completion: | |
|Residency Program: | |Year of Completion: | |
|Fellowship Program | |Year of Completion | |
|North Carolina Medical License Number: | |
|Subspecialty or Clinical Focus: | |
|Is your practice limited to neurology? | Yes | No |If no, additional practice area(s): | |
Section III
|Membership Type, Application Fee & Annual Dues: |
|amounts below represent the 2019 Membership Dues and the one-time $25 application fee. |
| $125 Active (practicing neurologist) | $125 Associate (physician or PhD | $60 Affiliate (non-physician allied |
| |in allied field) |health professional) |
| $0 Junior (resident or fellow-in-training) | $0 Emeritus (retired from active clinical practice) |
|Payment Options: | Check payable to NCNS | MasterCard | Visa | AMEX |
|Card number: | |Exp. Date: | |CVV: | |
|Applicant’s Signature: | |Date: | |
Please sign your completed form and return it with your payment by mail or fax to:
NCNS, PO Box 27167, Raleigh, NC 27611 | Fax: 919-833-2023
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