New Member Application – GEORGIA (GEA)

GEORGIA ELECTROLOGIST ASSOCIATION
Affiliate of the American Electrology Association

Required fields are marked with *

Full Name

Business Name

Preferred Mailing Address

Business Address (If Different)

Email Address

Business Phone #

Cell Phone

Yes No

Text Messaging

Yes No

Cell Phone #

Currently Practicing?

Yes No

State Licensed

Yes No

In Which State

License Number

Website Address

Which Modalities do you use?

Galvanic Shortwave Blend

Are You a Certified Professional Electrologist

Yes No

If So, What is your CPE #

Name of Electrolysis School Attended

Hours Completed

Graduation Date

Other Training/Apprenticeship (include instructor’s name, address, & phone #)

Upload/Attach the required Documents