Active Membership Application

MEMBERSHIP APPLICATION FORM

Please refer to our the GTSC Membership Benefits page to confirm your eligibility prior to completing the Membership Application Form. Applicants who do not meet the requirements of membership will be denied and payment refunded.

Privacy Policy: All information collected here is for GTSC use. GTSC will not give out any personal data on this site without your express permission.

Security Policy: We will protect personal information by reasonable security safeguards against loss or theft, as well as unauthorized access, disclosure, copying, use or modification.

Cancellation Policy: Cancellations will not be provided for membership of the General Thoracic Surgical Club unless rejected. Please contact info@gtsc.org regarding questions, or concerns.

Refund Policy: GTSC membership refunds will not be provided unless application is rejected.

Membership Dues

Membership Type *

Contact Information Contact Information

Email *

Re-enter your email *

Prefix

First Name *

Middle

Last Name *

Designation(s) *

Title *

Informal Name

Company *

Address 1 *

Address 2

Address 3

City *

State

Zip Code *

Country *

Website

Profile Photo

Phone Number *

Fax Number

CC Email

Include me in Membership Directories *
Yes No

Include me in Broadcast Email *
Yes No

Member Login/Password Member Login/Password

Please enter the Member Login/Password you would like to use to login to this website.

Your Member Login must be unique and must be at least 6 characters.
Passwords must be a minimum of 8 alpha-numeric characters with at least 1 number or 1 letter.

Member Login *

Password *

Confirm Password *

Additional Information Additional Information

Date of Birth (XX/XX/XXXX) *

Year Certified in Thoracic Surgery: *

Certificate Number: *

Percent of Practice Devoted to General Thoracic Surgery:(GTSC requires that applicants devote at least 50% of their practice to general thoracic surgery in order to qualify for membership) *
50%-75%
76%-100%

The application must be sponsored by two Active or Senior members of the club. Please list both sponsors name and contact information below. We may contact these individuals for verification.

Sponsor 1 Name: *

Sponsor 1 Email: *

Sponsor 2 Name: *

Sponsor 2 Email: *

The applicant must have two letters of support from individuals familiar with their practice. If the sponsors are familiar with their practice, they may also write the letters of support.

Letter of Support 1: * Allowed file types: doc,docx,pdf,ppt,pptx,xls,xlsx,txt,gif,jpg,png,jpe

Letter of Support 2: * Allowed file types: doc,docx,pdf,ppt,pptx,xls,xlsx,txt,gif,jpg,png,jpe

Please upload a complete list of all operations performed in the year prior to application and certified by the chief(s) of surgery at your institution(s). * Allowed file types: doc,docx,pdf,ppt,pptx,xls,xlsx,txt,gif,jpg,png,jpe

Payment Details Payment Details

Comments

Amount to Charge :

Payment Method:

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Bank Name:
Bank Account Holder Name:
Routing Number:
Account Number:
Account Type:

Name on Card:

Card #:

Expires:

CSC (What's this?):

Billing Street:

Billing Zip Code:

Enable Automatic Renewals?

Select "Yes" in order to be enrolled in automatic membership renewal. The above payment method will become your saved payment method, overwriting anything that may have been previously saved and will be used for future renewals. You can change the automatic renewal setting or saved payment method at any time in either the "Payment Method" or "Membership Auto-Renewal" tabs where you edit your profile.

No Yes

GTSC Executive Office: 5841 Cedar Lake Road · Suite 204 \| Minneapolis, MN 55416
	952.646-2048		info@gtsc.org