LASCA RENEWAL MEMBERSHIP ONLINE FORM













LOUISIANA AMBULATORY SURGERY CENTER ASSOCIATION
Your Name:
Your ASC:
Address:
City, State, Zip:
Telephone #:
Email:
Registrants from your ASC:
1.)
2.)
Name
Title
Email Address
Title
Email Address
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 2017 ACTIVE Membership (January 1, 2017 - December 31, 2017
3.)
4.)
5.)
$50 per person ~ LASCA Members
$75 per person ~ Members of other state ASC associations 

 AEU Credits Applied For From AORN and CASC