Pennsylvania Neurological Society Membership Application

Pennsylvania Neurological Society Membership Application

Application for Active Membership
Active Members shall be those physicians and APPs engaged in the practice of neurology in Pennsylvania who pay voluntary dues as set forth in Article IV. This entitles them to vote on issues before the membership, eligibility to serve on the Board of Directors including holding an office, and eligibility for financial and professional benefits as determined by the Board.

Active Member Benefits
- $100 discount off fee for Annual Meeting providing the latest updates in neurology
- Free posting for your practice listing (“position available”) on web site upon request
- Free listing for your office contact information on the PNS web site upon request
- Free professional biographical sketch on PNS web site upon request
- Vote on PNS business and elections of Board members and Officers
- Active members have the opportunity to hold office and serve on the Board
Questions? Contact info@paneurosociety.org.
Name*

First NameMiddle NameLast NameSuffix
Phone Number*

Area CodePhone Number
Email*
example@example.com
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Office/Clinic Name*
Office Address*

Street Address

Street Address Line 2

CityState

Zip Code
Pennsylvania State License #*
Date Issued*
Medical School*
Include city, state
Residency*
Date of Birth*

MonthDayYear
Date
Birth Place*
Would you like your practice's contact information made available to the public on our website?*

YesNo
Please list any other professional memberships you have*

Pennsylvania Neurological Society Membership Application

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