Membership

Membership Application

Membership is open to ACS Fellows and Associate Fellows. Benefits of the local chapter include networking opportunities that enable members to build strong professional relationships with surgical peers, opportunities to participate in advocacy activities at the state and federal levels that impact the practicing surgeon and patients, convenient educational meetings and local CME, leadership opportunities within the chapter council that can translate to future leadership roles within the College, a forum to engage and mentor young surgeons, trainees, and medical students and opportunities to learn about new products and services in the Exhibit Hall at the Annual Spring Meeting.

Membership Form

Name: *

Credentials *

Employer *

Work Phone *

Fax

Preferred Email *

*Email will be used for member communications.

Work Address

Address Line 1

Address Line 2

City

State / Province

Postal / Zip Code

Country

Preferred Mailing Address:

Home
Practice

FACS Designation (Fellow, Associate Fellow, Resident, Student, etc.) *

Year you became FACS, or Associate Fellow if applicable

National ACS Member Number

Gender

Male
Female

Year Born

Home Address

Address Line 1

City

State / Province

Postal / Zip Code

PRACTICE INFORMATION

Primary Practice Type

(Solo, Group, Hospital, Academic, Military, Other)

Primary Practice Specialty:

Primary area of Practice

Urban
Rural
Military

ADMINISTRATIVE CONTACT PERSON, If you have a support person who the Chapter may contact on your behalf, please provide his/her information:

Name

Phone

Type of Membership *

Retired - $0 Must have been granted retired status by the American College of Surgeons.
Resident - $0 Surgical residents and surgeons in research or surgical fellowship programs who meet the American College of Surgeons requirements for participation.
Medical Students - $0 Medical students in accredited allopathic or osteopathic medical schools, who meet meet the American College of Surgeons requirements for participation.
Paid Membership Options (Associate Fellow, Affiliate, Fellow)

1st year dues are waived for new members. Dues then are: Fellow- $150.00 Associate- $50.00 Retired, Senior, Lifetime, Students and Residents- $0

Signature

Date

Phone

Membership Application