Junior Membership App

Fields marked with * are required.

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

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

Application for Junior Fellowship (Only for Surgical Residents - All Specialties)

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.

M
F
Clear Selection

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


(Maximum characters: 2000)
You have characters left.

(Maximum characters: 2000)
You have characters left.
Colleague
Journal
Website
Other (indicate below)
Clear Selection

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.

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

 

MEMBERSHIP PROVIDES OPPORTUNITY

1516 N. Lake Shore Drive, Chicago IL 60610 · Phone 312-787-6274 · Fax 312-787-9289 Legal | Privacy | Copyright
image widget
image widget