Personal Information

Full Name (with degrees)*	Email*	NASS ID# (if known)
City of Residence	Country

2016 Membership Category/Dues (View Requirements)*

MDs and DOs (or international equivalent): Are you board certified?

Yes

Name of Certifying Board (the entity that grants your medical certification or license):

What percentage of your professional activities are dedicated to spine?*

<50%

50-100%

2016 Dues Payment (if applicable)

Card Number
Exp. Date
Name on Card**
Go Green! Eliminate future dues billing by signing up for automatic renewal using this card.
**By submitting this form, you are authorizing the North American Spine Society to charge your credit card any 2016 dues owed for your selected new category of membership. All requests for a change in membership category are pending approval of international degree or board equivalency as determined by the NASS Board of Directors; no changes in category will be accepted prior to Board approval. If, after requesting a change in category, an equivalent is not approved by the Board, any additional paid dues will be refunded in the original form of payment.