2024 Auxiliary Membership Application

Company Information

Name of Company
Address
City State Zip
Web Address
Generalized Email
Please provide a brief description of your company product or service:
CASA Auxiliary Members can be listed on our ASC Industry Vendors page. Please choose the category/categories you would like to be listed under Use ctrl (PC users) or command (Mac users) to multi-select:
Other Category
Auxiliary Members can be noted as a preferred vendor if you offer some type of discount to CASA members. Please describe the offered discount.
Discount

Business Contact

Primary Contact

First Name
Last Name
Title
Phone
Email
 

Secondary Contact

First Name
Last Name
Title
Phone
Email
 

Accounts Payable AP

(if applicable or different from above)
Accounts Payable First Name
Accounts Payable Last Name
Phone
Email

Membership Dues

Membership fees are due upon joining. Renewals are pro-rated and billed for the annual January payment.

Were you referred by a member or partner?
(please enter the name)

Code of Conduct for CASA Members

By submitting an application for membership or for renewal of membership, the Facility, Individual and/or Vendor acknowledges that it has reviewed the CASA Code of Conduct and Bylaws, and pledges, without reservation to adhere to the standards of practice and conduct set forth therein, with regard to the quality of ambulatory care provided and the management of all other aspects of the member’s operations as well as with regard to participation in the credentialing process itself. To review CASA’s complete Bylaws & Code of Conduct, please visit www.casurgery.org..

I have read and agree to the Code of Conduct for CASA Members
(please initial)
   - denotes required fields