Individual & Auxiliary Membership Application

Company Information

Name of Company or Individual
Address
City State Zip
Web Address

Personnel

Primary Contact

First Name
Last Name
Title
Phone
Fax
Email

Secondary Contact

First Name
Last Name
Title
Phone
Fax
Email
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Please provide a brief description of your company product or service:

Membership Fees

Membership fees are due upon joining.

Renewals are pro-rated and billed for annual January payment.

MEMBERSHIP FEE SCHEDULE

Were you referred by a member or partner?
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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
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