MSS Dues Renewal Form

MSS Dues Renewal Form

January 1, 2023 - December, 31 2023
MSS + YOU
Name*

First NameMiddle NameLast NameSuffix
Choose One*

MDDOMD, FACSDO, FACSOther
Preferred Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Practice Type*

AcademicPrivate PracticeCommunity Hospital EmployedMixed Model
Academic Program*

Hennepin HealthcareMayo ClinicUniversity of MinnesotaOther
Institution/Practice Name*
Preferred Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Twitter Handle
Do you have an administrative assistant that you would like us to send announcements about chapter events and programs?*

YesNo
Administrator Name

First NameLast Name
Admin Email
example@example.com
Phone Number
Please enter a valid phone number.
MSS + YOUR Surgical Specialty
Your Discipline

General SurgeryTrauma/Critical CareBreast SurgeryVascular SurgeryTransplant SurgeryThoracic SurgeryCardiac SurgeryOtorhinolaryngologyOrthopedic SurgeryUrologyPediatric SurgeryColorectal SurgerySurgical OncologyPlastic SurgeryMinimally Invasive/BariatricOther
MSS + YOUR Involvement

Get Involved in Your Local Chapter
Yes, I would like to be involved in the following:

MSS CouncilorYoung Fellows Association CommitteeWomen in Surgery CommitteeAdvocacy CommitteeCommission on CancerCommittee on TraumaCommittee ChairAssociate Fellow CommitteeDiversity and Inclusion Committee
MSS + YOUR Membership

MSS Membership Types
Active Members shall be Fellows and Associate Fellows of the American College of Surgeons residing or practicing in the state of Minnesota.

Fellow - Must have met all of the requirements and been formally admitted into Fellowship of the American College of Surgeons

Associate Fellow - Must be recognized by the American College of Surgeons as an Associate Fellow; category between Candidate Group and Fellowship

Affiliate Members are licensed registered nurses, nurse practitioners, physician assistants and pharmacists who are members of the American College of Surgeons
I am a*

FellowAssociate FellowAffiliate MemberRetired Member
Member Name*
Membership Options*
prevnext( X )
Fellow Dues
$175.00



Associate Fellow Dues
$175.00



Affiliate Dues
$125.00



Retired Member Dues
$75.00



Total

$0.00
Should be Empty:

MSS Dues Renewal Form

MSS + YOU

MSS + YOUR Surgical Specialty

MSS + YOUR Involvement

MSS + YOUR Membership