Membership Application

If you cannot provide a valid email address, you must use a print application. The print application can be downloaded here. It is STRONGLY suggested that you provide a valid email address that you check on a regular basis as many member benefits are transmitted electronically and depend on email transmissions.

PLEASE READ BELOW, YOUR APPLICATION WILL BE
IMMEDIATELY REJECTED IF:

Any required section is not completed.
You provide false or misleading information.
You attempt to circumvent any data validation implemented by the system.

Choose a Membership Type

Active Member ( 1 year @ $100.00 ) - Active Membership is open to Fellows of the American College of Surgeons (ACS)

Associate Member ( 1 year @ $100.00 ) - Associate membership is open to medical doctors who are non-Fellows of the ACS

Advisory Member ( 1 year @ $100.00 ) - Affiliate membership is open to healthcare providers in trauma centers and hospitals in the State of Florida who are non-physicians

Personal Information

Courtesy Title:

First Name:

Middle Name:

Last Name:

Suffix:

Degree:

Other Degrees

Email:

Job Title:

Date of Birth:

Gender:

How did you hear about the FCOT?

Why are you joining?

Please tell us why you want to join the Florida Committee on Trauma.

Reason:

Administrative Contact Person

If you have a support person who the Society may contact when you are busy, please provide his/her information..

Assistant's Name:

Assistant's Phone Number:

Assistant's Email

Contact Information

Choose mailing preference:

Office Address

Organization:

Street Line 1:

Street Line 2:

City:

State:

Zip/Postal Code:

Phone:

Fax:

Home Address

Street Line 1:

Street Line 2:

City:

State:

Zip/Postal Code:

Phone:

Fax:

About Your Practice

Profession:

Type of Practice:

Professional, Practice, or Organization Website (if applicable):

Promo Code:

Payment Information

Cardholder's First Name:

Cardholder's Last Name:

Expiration Date:

Card Type:

Card Number:

CVV:

Zip/Postal Code:

By joining FCOT, you agree to opt-in to receive all phone, fax, email, and other electronic communications sent by FCOT. To opt out of receiving these communications, please check here.

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PLEASE READ BELOW, YOUR APPLICATION WILL BE IMMEDIATELY REJECTED IF:

Choose a Membership Type

Personal Information

Why are you joining?

Administrative Contact Person

Contact Information

Office Address

Home Address

About Your Practice

Payment Information

PLEASE READ BELOW, YOUR APPLICATION WILL BE
IMMEDIATELY REJECTED IF: