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SOUTH FLORIDA CHAPTER
of the
American College of Surgeons
Membership Application
Membership is open to ACS Fellows residing in the following Florida counties
• Broward • Miami-Dade • Monroe • Palm Beach
_____ Yes, I would like to become a member of the South Florida Chapter,
American College of Surgeons
_____ Enclosed is my check for the 2009-2010 dues in the amount of
$160.00 for Active membership
_____ Please bill me for my membership dues at the address below.
NAME____________________________________________
YEAR FACS_______________________________________
SPECIALTY_______________________________________
BUSINESS NAME___________________________________
ADDRESS_________________________________________
CITY, STATE, ZIP________________________________
PHONE____________________ FAX__________________
E-MAIL__________________________________________
Direct completed application and questions to:
Bill Bouck, Chapter Administrator
SFC/ACS
PO Box 540363
Opa-Locka, FL 33054
Phone: 305-687-1367
Fax: 305-687-2490
E-mail: wtbouck@bellsouth.net
Applicant Signature ________________________
Date______________
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