1330 W. Peachtree Street, Suite 500, Atlanta, GA 30309-2904 / 404-881-5020 phone / 404-249-9503 fax
Please print and fax to the chapter office or scan and email to jrice@gaaap.org
Date: ______________________
Name: __________________________________________________ MD DO PA PNP other_____________
Address: _______________________________________________________________
Phone: _________________________________________ Fax: __________________________
E-Mail: ________________________________
Available to start: ________________________
Full/Part time: ___________________________
Desired geographic location (City or Region of State): __________________________
Medical School: ______________________ Year graduated :______________________
Residency: ______________________________________________________________
Other key interests:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Other Notes:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please notify the Chapter office when you accept employment.
* Will keep on file at Georgia chapter office one year