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Allied Member Application

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Application for Allied Membership (Only for Physician Assistants & Nurse Practitioners)

Please fill out the application completely. Omissions will increase processing time.
Only submit this application if you are licensed and practicing in the United States.

First Name *
Middle Initial
Last Name *
Are you a Nurse Practitioner (NP) or a Physician Assistant (PA)
*
List your academic degrees:
Office Address *
Office City, State and Zipcode *
Work Phone Number *
Email Address *
Date of Birth *
Citizenship *
Spouse's Full Name
Sex *

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State(s) where license(s) held.
Include license number and expiration date.
(Maximum characters: 2000)
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List any certifications held and when obtained.
(Please note that certification is not required.)
(Maximum characters: 2000)
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List other association memberships.
(Maximum characters: 2000)
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Applicants must provide names and contact information below for two surgeons with whom you are acquainted that can verify your professional status and character. A referral form will be sent to the individuals listed. If one of your references is a Fellow of ICS, only one referral is necessary.

Reference 1 Name *
Ref 1 Address, City, State, Zip and Email *
(Maximum characters: 2000)
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Reference 2 Name
Ref 2 Address, City, State, Zip and Email
(Maximum characters: 2000)
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How did you learn about the International College of Surgeons?

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By clicking submit you agree to the following terms:

Recognizing that an investigation of my qualifications is necessary prior to becoming a member of the ICS, I hereby authorize said College, its Qualifications and Interim Council, officers, agents, employees and representatives to seek any and all documents at their discretion to evaluate this application for membership.

I hereby authorize all persons, firms, corporations - including and without limitation hospitals, medical associations and physicians - to divulge to the ICS any information, letters, or written material relating in any manner to my professional qualifications, clinical competency, character or any other matter that is directly or indirectly related to this application. With respect to any disclosures, discussions, reports, communications, and the evaluations made herewith, I do hereby release the ICS, its Qualifications and Interim Council, officers, agents, employees and representatives and any other persons, firms, corporations, hospitals or individuals delivering any information or written material to any of them from any and all civil liability as a result of any actions or inactions by any of them as a result thereof.

The normal application fee of $100 that is required with your submission has been reduced to $50 for a limited time. This fee will be applied to your first year dues, which are currently $100. *

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Your form submission WILL be encrypted using SSL to ensure your privacy.

 

81st Annual Surgical Update of the United States Section

May 2-4, 2019

Nemacolin Woodlands Resort
Farmington, Pennsylvania
Approximately 90 minutes from the Pittsburgh Airport

 

MEMBERSHIP PROVIDES OPPORTUNITY

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