2010 AASCA Membership Renewal

Please complete the following form:

Name of Facility *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
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.
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.