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Application for Fellowship   (Click here if you are a surgical resident - all specialties)

Only submit this application if you are licensed and practicing in the United States.

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

Medical Students & Surgical Residents in training may apply for Junior Fellowship by clicking HERE.

PAs and NPs may apply for Allied Membership by clicking HERE!

First Name *
Middle Initial
Last Name *
Title / Degree (only MD or DO qualify) *
Office Address *
Office City, State and Zipcode *
Office Phone Number *
Office Fax
Email Address *
Primary Specialty *
Secondary Specialty
Date of Birth *
Citizenship *
Sex *

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Reference 1 Name
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Reference 3 Name
Ref 3 Address, City, State, Zip and Email
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List Board Certifications held and when obtained.
(Please note that Board Certification is not required. A curriculum vitae will be required if not Board Certified.)
List other medical society memberships.
State(s) where license(s) held. Include license number and expiration date.
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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