ANNUAL APPLICATION FOR MEMBERSHIP IN THE INDIANA CHAPTER OF THE AMERICAN COLLEGE OF SURGEONS 2010
___________________________________hereby applies for membership in
the Indiana Chapter of the American College of Surgeons. If accepted by
the Executive Council, the undersigned agrees to abide by the Bylaws of
the organization. The undersigned understands that failure to pay the annual
membership fee is cause for termination of the undersigned's membership
by the Executive Council.
Dated this ______________________day of ___________________________2010
_______________________________ Printed signature
_______________________________ Written signature
| _______ $125 Active Fellow |
_______ $0 Candidate Fellow |
|
_______ $0 Resident |
| _______ $ 62.50 Associate Fellow |
_______ $ 0 Retired/Completed |
Please return your membership fee check made payable to the Indiana Chapter,
ACS to:
Carolyn Downing, Chapter Administrator
Indiana Chapter, ACS
322 Canal Walk
Indianapolis, IN 46202
TEL (317) 261-2060
FAX (317) 261-2076
cdowning@ismanet.org
FOR USE BY THE INDIANA CHAPTER OF THE AMERICAN COLLEGE OF SURGEONS,
INC. ONLY.
ACCEPTED BY:
DATED
ACCEPTED BY:__________________________________DATED ____________________
Secretary/Treasurer, Indiana Chapter, ACS
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