Please fill out the application completely. Omissions will increase processing time.

Application for Junior Fellowship
Only for Surgical Residents and Medical Students - All Specialties

Please fill out the application completely. Omissions will increase processing time.
Only submit this application if you are living and training in the United States.
Medical school students must be enrolled in a medical school in the US or
if attending medical school outside the US you must be a US citizen.

First Name *
Middle Name
Last Name *
Title (highest degree achieved) *
Office Address *
Office City, State and Zipcode *
Phone Number *
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Office Fax
Email Address *
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Date of Birth *
Citizenship *
Primary Specialty *
Secondary Specialty

If you are being referred by an ICS Fellow (does not include a Junior Fellow) and they will be your reference, only one reference is required. The preference is that your Residency Program Director serves as your reference, although any attending with whom you work will be acceptable.

Reference 1 Name *
Ref 1 Address, City, State, Zip and Email *
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Reference 2 Name
Ref 2 Address, City, State, Zip and Email
List your other medical society memberships below.
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How did you learn about the International College of Surgeons?

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Please attach a copy of your CV if available in electronic format. This will expedite the approval process.

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.

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