2024 Auxiliary Membership Renewal

Company Information

Name of Company
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.

Business Contact

Primary Contact

First Name
Last Name

Secondary Contact

First Name
Last Name

Accounts Payable AP

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

Membership Dues

Renewals are billed for the annual January payment.

The CASA PAC is a voluntary political organization that contributes to candidates for state office who share our philosophy and vision of the future of medicine. Political law and the CASA PAC Committee determine how your contribution is allocated. Contributions to PACs are voluntary and not limited to the suggested amounts.
PAC Contribution Rules: Corporate/Company can contribute $9,100 per calendar year. If an individual owns 50% or more of the contributing company, the individual’s personal contribution and the company’s contribution cannot exceed $9,100. PAC contributions can only be used for political purposes. These funds cannot be used to pay for lobbying efforts.
Contributions are not deductible for state or federal income tax purposes. Any contribution of $100 or greater will be publicly reported.


If your organization is prohibited from participating in the CASA PAC, you can still be involved by contributing to the CASA Advocacy Fund.

Voluntary PAC Contribution/Advocacy Fund

If your organization would like to participate in CASA PAC, please indicate the amount below:
Amount $
If your organization would like to participate in the Advocacy Fund, please indicate the amount below:
Amount $

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)
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