ANNUAL APPLICATION FOR MEMBERSHIP IN THE
___________________________________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 ___________________________2005
_______________________________ Printed signature
_______________________________ Written signature
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_______ $75 Active Fellow |
_______ $0 Candidate Fellow |
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_______ $0 Resident |
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_______ $ 37.50 Associate Fellow |
_______ $ 0 Retired/Completed |
Please return your membership fee check made payable to the
Indiana Chapter, ACS to: