Junior Membership App

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

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

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

First Name *
Middle Name
Last Name *
Title (degree) *
Office Address *
Office City, State and Zipcode *
Phone Number *
Phone number type *
Office Fax
Email Address *
Sex *

Clear Selection
Date of Birth *
Citizenship *
Primary Specialty *
Secondary Specialty

If you are being referred by an ICS Fellow and they will be your reference only one reference is required.

Reference 1 Name *
Ref 1 Address, City, State, Zip and Email *
(Maximum characters: 2000)
You have characters left.
Reference 2 Name
Ref 2 Address, City, State, Zip and Email
List your other medical society memberships below.
(Maximum characters: 2000)
You have characters left.
How did you learn about the International College of Surgeons?

Clear Selection
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.

Fields marked with * are required.

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

1524 N. Lake Shore Drive | Chicago IL 60610 | 312.787.6274
Legal | Privacy | Copyright | GDPR
2021 United States Section of the International College of Surgeons
All Rights Reserved.