HENRY N. HARKINS SURGICAL SOCIETY
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