Make checks payable to:
MISSOURI CHAPTER - AMERICAN COLLEGE OF SURGEONS.

Keep the stub for your record of payment. Please complete this form and return it with your yearly dues, payable beginning on December 7, 1998.

Check One:

_______ 1999 Annual Dues for Active Fellows - $100.00

_______ 1999 Annual Dues for Active Associate Fellows - $50.00

_______ 1999 Annual Dues for Active Retired Members are exempt.

_______ 1999 Annual Dues for Active Chapter Members who have
turned 70 but have not retired are EXEMPT.

MAIL TO: Linda Wheelen, Chapter Administrator
Missouri Chapter - American College of Surgeons
P.O. Box 4562, Springfield, MO 65808
Phone: (417) 869 - 5222

(Please print or type both home and office addresses)

NAME ___________________________________ SPECIALTY _________________

ADDRESS (OFFICE)________________________ HOSPITAL __________________

CITY _________________ ZIP CODE __________ PHONE _____________________

ADDRESS (HOME) _________________________ FAX _______________________

CITY __________________ ZIP CODE _________ PHONE _____________________

SPOUSE'S NAME __________________________

MISSOURI CHAPTER AMERICAN COLLEGE OF SURGEONS

1999 Membership Card

____________________________________
signature

(Please detach and retain)

1999 ANNUAL DUES