HENRY N. HARKINS SURGICAL SOCIETY
5714 134th Pl SE, Suite A18-#58
Everett, WA 98208
Email: UWHarkins@gmail.com
5714 134th Pl SE, Suite A18-#58
Everett, WA 98208
Email: UWHarkins@gmail.com
2014 Statement of Dues
Your annual dues payment contributes to the support of the Harkins Society and allows you entrance
to the annual membership reception at the American College of Surgeons Clinical Congress.
Member Category:
____ $100 Active Member (residing in Washington State)
____ $50 Allied Member (residing outside Washington State)
____ $50 Retired
Dues Waived for Residents/Fellows
Optional Contribution
____ Yes! I would like to contribute to the Harkins Society Fund for Resident Support that provides residents
with needed supplies (e.g. loupes, textbooks, etc.). I am enclosing an additional $_______________.
**Contribution to the resident fund is tax deductible and you will receive a receipt.
Total Enclosed (dues payment + resident contribution): $_______________
Member Information
NAME ____________________________________________________________
TITLE ____________________________________________________________
INSTITUTION ____________________________________________________________
ADDRESS ____________________________________________________________
____________________________________________________________
____________________________________________________________
PHONE ____________________ EMAIL ________________________________________
Please return this form and a check made payable to the Henry N. Harkins Surgical Society to:
Henry N. Harkins Surgical Society
ATTN: Jennie Paxson
5714 134th Pl SE, Suite A18 - #58
Everett, WA 98208
Find us on Facebook: https://www.facebook.com/groups/305217632830951/
W-9 and/or personalized invoice required to meet institutional documentation standards available upon request by emailing: UWHarkins@gmail.com
SAVE THE DATE
Tuesday, October 28 – ACS Reception, Hilton, San Francisco, CA
Friday, November 21 – Annual Meeting and Dinner, Seattle
Tuesday, October 28 – ACS Reception, Hilton, San Francisco, CA
Friday, November 21 – Annual Meeting and Dinner, Seattle