PO BOX 14940
Baton Rouge, LA 70898 
Phone: (225) 326-3180
LASCA ASSOCIATE MEMBERSHIP ONLINE APPLICATION FORM














LOUISIANA AMBULATORY SURGERY CENTER ASSOCIATION
Applicant Name:
Applicant's Business:
Address:
City, State, Zip:
Telephone #:
Fax #:
List Contact Person(s) - (maximum of two) - to whom LASCA information should be sent (Newsletters, special notices)
1.)
2.)
Name
Title
Email Address
Name
Title
Email Address
Please send your website advertisement and eNewsletter advertisement to:
sarah.heath@checkmate-strategies.com

I/we hereby apply for membership in the Louisiana Ambulatory Surgery Center Association (LASCA) and agree to abide by such By-Laws and/or rules of the Association which may be enacted. The information herein is true and to the best of my/our knowledge. We hereby apply for membership in the Louisiana Ambulatory Surgery Center Association (LASCA) and agree to abide by such By-Laws and/or rules of the Association which may be enacted. The information herein is true and to the best of my/our knowledge.  By submitting this information below, this is our electronic signature.
By clicking on the submit button below, you will be directed to the payment page.  Annual Dues are $500.00 for LASCA Associate Membership