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Indiana Chapter Membership Application Form

I hereby apply for membersip in the Indiana Chapter of the American College of Surgeons. If accepted by the Executive Council, I agree to comply by the Bylaws of the Chapter. I agree that failure to pay the annual membership fee is cause for termination of my membership. Dated this _____________ day of _______________ 20 ______
_____ $125.00 - Active Fellow _____ $0 - Retired/Senior - Age 70+ and still in practice _____ $62.50 - Associate Fellow _____ $0 - Resident _____ $62.50 - Affiliate _____ $0 - Medical Student
You can print this completed form and return to the address below, with your check made payable to: Indiana Chapter, ACS
OR, you can select "SEND" below, click on "PAY YOUR DUES NOW", and pay via PayPal.

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INDIANA CHAPTER OF THE AMERICAN COLLEGE OF SURGEONS
Email
tomdixon18@infacs.org
Phone
(317) 698-2105
Address
49 Boone Village, #274 Zionsville, IN 46077
Service Area
Indiana
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