IAASC Membership Application

Please include your facility information below:

Organization
Address
City State Zip
Phone Fax
Website

Your Representatives

You may include up to four members, but please designate only one 'voting member' who will also be listed as primary contact for your facility in our 'Find an ASC' online directory.
1. Voting Member
First Name
Last Name
Title
Phone
Email
2. Additional Representative
Name
Title
Phone
Email
3. Additional Representative
Name
Title
Phone
Email
4. Additional Representative
Name
Title
Phone
Email

Calculate Your Dues

Use the following guidelines, based on the number of cases performed in 2013.
   - denotes required fields