Application for Associate Membership

This application is for those with evidence of Active Membership in the Society of Gastroenterology Nurses and Associates (SGNA), or RN, Technician, Physician Assistant or Nurse Practitioner employed in the field of Gastrointestinal Endoscopy, but who does not perform endoscopy. For a full listing of requirements and benefits for Associate Membership, please click here.

Associate Membership Price:

SGNA Member - $75
Non-SGNA Member - $100
GIE subscription - $65.00 (optional)

***Please note refunds will NOT be granted if application is not complete within 120 days of submission.***

Personal Information

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

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

Date of Birth:	Place of Birth:	Citizenship:

Spouse First:	M.I.:	Last:	Suffix:

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

Are you currently a Member in good standing of the Society of Gastrointestinal Endoscopy Nurses and Associates (SGNA)?
YesNo If yes, SGNA Member #:

Reasons for Joining the Society

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

Personal Interests (Check all that apply)

ASGE has formed 8 special interest groups (SIGs), and currently has one proposed SIG that is not yet active.

Please check any SIGs for which you would like more information. Ambulatory Endoscopic Centers
Capsule Endoscopy
Endoluminal Therapy for Esophageal Disease
Endoscopic Ultrasonography
Enternal Nutrition
Gastroesophageal Reflux Disease
Invention & Innovation
Small Bowel Endoscopy

Please check any of the following areas for which you would like to receive announcements of news or opportunities.
Legislative Updates
Practice Management Tips & Tools
Research Grant Opportunities
CME Opportunities
ASGE Special Events
ASGE Practice Guidelines & Technology Assessments
New ASGE Products
Natural Orifice Translumenal Endoscopic Surgery (NOTES™)

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.

ASGE LOG IN

MEMBERSHIP

Application for Associate Membership