MSS Membership Application

Minnesota Surgical Society

Membership Application
MSS + YOU
Name *

First Name Middle Name Last Name Suffix
Choose all that apply *

MD DO MBBS FACS Other
I am a *

Fellow Associate Fellow Retired/Senior Member Affiliate Member
ACS Membership Number *
Practice Type *

Academic Private Practice Community Hospital Employed Mixed Model
Academic Program *

Hennepin Healthcare Mayo Clinic University of Minnesota Other
Institution/Practice Name *
Preferred Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Preferred Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Administrator Name

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

General Surgery Trauma/Critical Care Breast Surgery Vascular Surgery Transplant Surgery Thoracic Surgery Cardiac Surgery Otorhinolaryngology Orthopedic Surgery Urology Pediatric Surgery Colorectal Surgery Surgical Oncology Plastic Surgery Minimally Invasive/Bariatric Other
MSS + YOUR Involvement

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

MSS Councilor Young Fellows Association Committee Women in Surgery Committee Advocacy Committee Commission on Cancer Committee on Trauma Committee Chair
MSS + YOUR Membership

MSS Membership Types
Member Name *
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.

Retired/Senior Members Any retired members in good standing, having attained the age of 70 years, shall.
Membership Options *
prev next ( X )
Fellow
$ 175.00

Associate Fellow
$ 175.00

Affiliate Member
$ 175.00

Retired Member
$ 75.00

Total

$ 0.00
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Minnesota Surgical Society

MSS + YOU

MSS + YOUR Surgical Specialty

MSS + YOUR Involvement

MSS + YOUR Membership