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
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