Membership Application Form | Indiana ACS

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.