New Member   ________        Renewing Member _______

 

Membership Year: ________ (ASCI Membership follows calendar year, Jan-Dec.)

 

PRINT INFORMATION

Name
Position/Title
Facility/Company
Department/Suite
Street Address
City
State
Zip
E-mail
Phone (Business)
Phone (Cell)
Phone (Home)
FAX – Business
FAX – Other

 

Annual Dues $25.00    

Make check payable to:            ASCI

Mail Membership form and Check to:

                                                ASCI

c/o Alabama Hospital Association

Attn: Public Relations Department

500 North East Boulevard

Montgomery, AL. 36117

 

 

I WOULD BE WILLING TO SERVE (please circle):

 

Site Coordinator (This person coordinates all activities for ‘distant/remote’ meeting participation.)

 

Committee Chair (Committees include Education/Programs; Communication/Publications; Nomination)

 

Committee Member (Committees include Education/Programs; Communication/Publications; Nomination)

 

To better server your needs, please indicate program topics or areas of interest.

1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________
4. ______________________________________________________________