Personal Information
Full Name (with degrees)*
Email*
NASS ID# (if known)
Updated Contact Information (if applicable)
This is a home address
Address
City, State, Zip
Country
Are you retired from the practice of spine care?*
Yes
No
Optional $100.00 2016
The Spine Journal
(
TSJ
) and
SpineLine
Subscription Payment
I do not wish to receive an print subscription to TSJ and SpineLine
Card Number
Exp. Date
Name on Card**
**
If you choose the optional $100 subscription, by submitting this form, you are
authorizing the North American Spine Society to charge your credit card the prorated amount of your subscription for the remainder of the 2016 calendar-year.
All requests for emeritus status will be reviewed and confirmed by the NASS membership department; you must have been an active NASS member for at least fifteen (15) years to be eligible for emeritus status. No charge will be made to your card until eligibility for emeritus membership is confirmed.