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NYSAASC 2017 Membership Application (Facility)

New York State Association of Ambulatory Surgery Centers , Inc
2017 NYSAASC Facility Membership Application

Membership in the New York State Association of Ambulatory Surgery Centers requires that a facility be a New York State licensed Article 28 facility. 2017 dues are set $650.00. Please complete the online registration below or download this form and mail the completed form and your check to:

NYSAASC
P.O. Box 8
Elma, NY  14059

Checks should be made payable to: NYSAASC.

Facility Name:
Specialty:
Facility Address:
NYS Operating Cert. #:
Facility Phone:
-
Facility Fax:
-
Facility E-mail:
Facility Adminisrator Name:
Facility Administrator E-mail:
Clinical Nurse Manager Name:
Clinical Nurse Manager E-mail:
Benchmarking Coordinator Name:
Benchmarking Coordinator E-mail:
Medical Director Name:
Medical Director E-mail:
2017 Annual Dues
 $ 

WE VALUE YOUR PARTICIPATION
YOU ARE AN IMPORTANT PART OF OUR ORGANIZATION