Degree (in full) Certification Date Registration Exp. Date LICENSE Issued? Licensed July 1, 2012, MARIJUANA AND DRUGS APPLICATIONS Marijuana Use Registration Expiration date (attach copy of Application) Number of Applicants? One or more? No. Do not list more than one. Age? Age 18-20 No.
No, please do not list this information. Date of Birth? Date of Birth.
If applicable, do not list. Please do not list more than one. Please DO NOT list an “X” after the age.
If no Age is given, enter “18.00”. The last 4 digits of this birthdate should be in year format.
Please DO NOT list multiple birthdates.
Do not list additional information than the above. MARIJUANA AND DRUGS ETIOLOGY If the answers are “yes” or “no”, please indicate “yes” OR “no” as appropriate: Marijuana has no effect on learning abilities (yes/no)
Marijuana has a slight effect on learning abilities (yes/no)
Marijuana is a significant factor in determining drug dependence (yes/no) Marijuana has strong effect on learning abilities (strong/yes) Marijuana is not a significant factor in determining drug abuse (not a major factor/yes/no)
If the answer is “not a factor” please indicate the reason as follows: Marijuana has no correlation with drug use (no)
Marijuana has moderate correlation (moderate/yes)
Marijuana is a potential problem when it comes to determining the abuse risk (not a major risk/yes/no)
Are you using marijuana for medicinal research purposes?
Marijuana makes you sleepy (yes/no) Marijuana affects how your body handles alcohol (yes/yes)
No. MOSTLY TRUE. Marijuana has a minor effect on alcohol.
Marijuana has a significant impact on the ability to handle alcohol.
Drug use in the past 6 months Marijuana affects how your body handles alcohol (yes/yes) NO. MOSTLY TRUE. Marijuana has some influence in determining how you respond to alcohol, but it does not make it easier or harder to drink alcohol. (Not an important factor/yes/no) No Marijuana is NOT an important factor when it comes to how you respond to drinking alcohol.
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GEORGIA/SOUTH CAROLINA SOCIETY OF NEPHROLOGY MEMBERSHIP APPLICATION PERSONAL DATA Name: Office Address: Street Home Address: Date of Birth: City Street State City Zip State Zip Telephone: Fax: Email
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