Date*
Name*
Email Address*
Phone Number*
Date of Birth*
Business Address*
Name of School*
City & State or County*
Years*
Degree*
Residency*
Fellowship*
Are you licensed to practice in the State of New York?* YesNo
License No.*
Are you a member of The Medical Society of the State of New York?* YesNo
Are you certified by The American Board of Neurological Surgeons?* YesNo
Are you Board Eligible?* YesNoN/A
You must be sponsored by two active members of the society. Who are your sponsors:*
Date and Entry into Active Duty:
Expected Date of Discharge:
Rank
Duty Station
Branch
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