___________________________________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 ______________     20__

_______________________________ Printed signature

_______________________________ Written signature

_______ $125 Active Fellow  _______ $0 Resident Member 
_______ $ 62.50 Associate Fellow _______ $0 Medical Student Member 
_______ $ 62.50 Affiliate Member _______ $ 0 Retired/Senior* 
* Senior is age 65+ and still in practice

Please return your completed form and membership fee check (if applicable) made payable to the Indiana Chapter, ACS to:
Tom Dixon, Chapter Executive
Indiana Chapter, ACS
49 Boone Village # 274
Zionsville, IN  46077
TEL (317) 698-2105
dixonest71@gmail.com

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



Indiana Chapter American College of Surgeons

Tom Dixon, Chapter Executive
49 Boone Village # 274
Zionsville, IN 46077

317-698-2105
tomdixon18@infacs.org