Apply for Membership "*" indicates required fields Thank you for recognizing the importance of supporting your local neurology community and applying for membership in the Washington State Neurological Society. Your participation and financial support is essential as we continually strive to strengthen our organization. Contact Information Name First Last TitlePractice/Group NamePractice Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Practice PhonePractice Email Home Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home PhoneHome Email Preferred Choice for WSNS Correspondence Home Work SubspecialtiesEDUCATION: (School Name/Location & Years Attended)Premedical EducationMedical SchoolResidencyFellowshipDate of Board CertificationBoard Eligible Yes No Professional Society MembershipsMEMBERSHIP TYPEOne-Year Membership Dues Active - $150.00 - $150.00 Affiliate (PA/ARNP) - $100.00 - $100.00 Junior (Resident) - $25.00 - $25.00 Emeritus - $0.00 - $0.00 Out of State - $125 - $125.00 Military - $75.00 TOTAL Payment Method*Credit Card American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name INQUIRIES: Contact the Association Executive, at the WSNS Office at 206-956-3635 or send emails to admin@washingtonneurology.org. Δ
