California License Number______________________________ Year__________________

American Board of Neurological Surgery status:     Certified ________________  Year________________

Date letter rec’d from American Board________________   Eligible for exam_______________________

Other _____________________________________________________________________________
(Enclose copies of Certification or letter from American Board)

MEMBERSHIPS:
Fellowship, American College of Surgeons  ____               
American Medical Association  ____               
American Assoc of Neurological Surgeons  ____               
Congress of Neurological Surgeons ____                
California Medical Association       ___               

Other local or regional neurological society memberships:
_________________________________________________

I hereby apply for membership in the California Association of Neurological Surgeons and agree to abide by the published Bylaws. 
Please call the CANS office if you would like to receive a copy of the bylaws.)

Signature of applicant ________________________ Date___________________

This application for membership is endorsed by the following member of CANS:

Member signature ____________________________________Date____________________

Printed last name________________________________________

Your application must be returned with a  $50 application fee.
Annual dues for first year of membership (to be collected January of next year) are $175 and $350 thereafter.
Please pay by check or credit card (VISA or MasterCard only):

card number: ______________________________  exp date: __________________
name as it appears on card (if different from above)_____________________________

Contributions to the California Association of Neurological Surgeons are not tax deductible as charitable contributions; however, they may be tax deductible as ordinary and necessary business expenses.

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Please complete this form and return to CANS at fax 916 457-8202 (alternate fax 916 457-2211) or mail to:
CANS, 5380 Elvas Ave., Ste. 216, Sacramento, CA 95819.
Contact 916 457-2267 or janinetash@sbcglobal.net if you need additional information.
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FOR CANS OFFICE USE:  
Date application received _______________ Date of Annual Meeting for approval ________
Check number _________Date__________     or Credit card approved______
Additional information requested ___________________________________________________