2010 AASCA Membership Application

Please complete the following form:

Name of Facility *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Fax - (###) - ### ####
Contact Person * First Last
Please list the name of the person who would be a point of contact for issues, questions or decisions regarding your facility's membership with AASCA.
Email *

Enter the email address of the Contact Person listed above. We will use this address to send periodic correspondence.
Web Site
Administrator First Last
Business Office Mananger First Last
Type of Facility *

Please tell us which types of procedures your facility primarily performs.
Annual Case Volume *

Please tell us how many procedures you perform on an annual basis. We use this data to calculate your yearly membership fee.