MSS Membership Application

Minnesota Surgical Society

Membership Application
MSS + YOU
Name*

First NameMiddle NameLast NameSuffix
Choose all that apply*

MDDOMBBSFACSOther
I am a*

FellowAssociate FellowRetired/Senior MemberAffiliate Member
ACS Membership 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
Preferred Email*
example@example.com
Phone Number*
Please enter a valid phone number.
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 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 Payment

Fellow

$175.00

Associate Fellow

$175.00

Affiliate Member

$125.00

Retired Member

$75.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Minnesota Surgical Society

MSS + YOU

MSS + YOUR Surgical Specialty

MSS + YOUR Involvement

MSS + YOUR Membership

Membership Payment