I hereby apply for membersip in the Indiana Chapter of the American College of Surgeons. I understand that membership in the American College of Surgeons (ACS) is required for membership in the Chapter. 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 ______
_____ $200.00 - Active Fellow _____ $0 - Retired/Senior- Age 70+ and still in practice
_____ $100.00 - Associate Fellow _____ $0 - Resident
_____ $100.00 - Affiliate _____ $0 - Medical Student
Chapter membership must be preceeded by membership in the American College of Surgeons (ACS). Enter your membership number below.
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 with a credit card through PayPal.