Application for Practice Managers, Affiliate Membership

For PharmaDs, Practice managers, Directors and Administrators

This application is limited to those individuals who do not practice endoscopy but demonstrate special interest in the broad field of gastrointestinal endoscopy, without personally having the endoscopic training or skills. For a full listing of requirements and benefits for Affiliate Membership, please click here.

Affiliate Membership Price: $100

***Please note refunds will be granted for denied or incomplete applications, minus a $50 administrative fee when payment has been made.***

If endoscopy is your practice, ASGE is your partner.

Personal Information

*First:	M.I.:	*Last:	Suffix:

Prof. Designations:	Gender:	Ethnicity:
	MaleFemale
Gender, Ethnicity and Citizenship information are collected for statistical purposes only.

Date of Birth:	Place of Birth:	Citizenship:

Contact Information

Business Information

*Position/Title:	*Business/Institution:

Address:	Address:

City:	State/Province:	Postal Code:	Country:

Telephone:	Fax:	E-mail:

Home Information

*Address:	Address:

*City:	*State/Province:	*Postal Code:	*Country:

*Telephone:	Fax:	*E-mail:

Communication Preferences

*Preferred mailing address for all ASGE mailings (GIE and Member Communication): HomeBusiness

*Preferred e-mail address for Scope and Member Alerts:HomeBusiness

*Preferred e-mail format:HTMLText

Primary Areas of Interest

If any of the following information is not applicable, please indicate by entering NA in the required field. (You can enter multiple items, separated by a comma.)

*Within Practice Managment

*Within Endoscopy:

Education

If any of the following information is not applicable, please indicate by entering NA in the required field.

*Institution	*Degree	*Date
*College or University

Medical

Reasons for Joining the Society

(Check all that apply)
EducationAdvocacy/Legislation
ProfessionalismGIE
Discounted registration to DDWAccess to members only website
Other (please specify below)

Census (Check all that apply)

Fax Transmission Permission

By providing the fax number(s) and my signature below I authorize the American Society for Gastrointestinal Endoscopy (ASGE) and the American Society for Gastrointestinal Endoscopy Foundation to send me facsimiles, that may include education information, promotional materials, advertising, and other commercial materials considered to be official ASGE correspondence to its members, so that I can take full advantage of the various programs, services and member benefits offered by the American Society for Gastrointestinal Endoscopy.
NOTE: ASGE does not release, sell or grant permission for the use of membership fax or e-mail information to any outside company or organization. This contact information is solely for the use of ASGE. Once consent is provided it will remain in effect until a change in notification is made to ASGE. If you change organizations and/or obtain a new fax number you must complete and submit a new consent form. If you have multiple fax numbers all numbers must be listed. Only those numbers on file at ASGE will be used for fax correspondence.

Please list at least one fax number below that can be used to provide you with the latest association information.

Terms & Conditions

I authorize the American Society for Gastrointestinal Endoscopy to obtain information from societies, hospital staffs, members and any other source regarding this application and my qualifications for membership, which information, whether or not solicited by the Society, may be kept confidential by the Society.
*I certify that the above information is accurate.

*Enter your name in the box above to act as your signature.

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Application for Practice Managers, Affiliate Membership