Membership Application Membership Category Active Member ($1,000.00) Membership is available for ASCs licensed in the state of Illinois. Please send proof of license with your application. ASC Information Include this facility in the member directory of the website. Facility Name (the legal name of your ASC) Facility Address Line 1 Facility Address Line 2 Facility Address Line 3 Facility City Facility State Facility ZIP (please include all nine digits) Facility Phone Facility FAX Facility Website URL Facility Staff Administrative Director/Business Manager Name (This individual will be listed as the contact to receive annual dues invoices) Administrative Director/Business Manager Email Medical Director Name Medical Director Email Director of Nursing Name Director of Nursing Email Individual authorized to vote at any meeting of the membership Authorized Voter Email Additional Facility Information Please Check ALL Accreditation: (Check all that apply) TJCAAAHCHFAPAAAASF Please Check ALL Facility Specialty/Services Provided: (Check all that apply) CardiovascularOral/MaxillofacialPain ManagementDermatologyOphthalmologyPlasticGeneral SurgeryLaser Eye SurgeryPodiatryGastroenterologyOrthopedicsThoracicNeurologicalOtolaryngologyUrologyOB/Gynecology Year Facility Opened: Number of Operating Rooms: Number of Procedure Rooms: Annual Number of Surgeries: Medicare Certified: --Select -- Yes No ASC Illinois License #: TOTAL AMOUNT DUE: Payment Information (must be made in U.S. dollars) CheckCredit Card --Select-- Visa MasterCard American Express Card Type Name As It Appears on Card Credit Card Number Expiration Date (MMYY) Card Verification Number Billing Information Billing Street Address Billing ZIP Code If paying by check, make check payable to: IASCA Mail payment to: Illinois Ambulatory Surgery Center Association Two Woodfield Lake 1100 E. Woodfield Road, Suite 350 Schaumburg, IL 60173 Signature Email Address Telephone Number Signature Date I Agree that I represent and acknowledge that: I have read, understood, and consented to electronic delivery of the data collected and payment entered above. I have granted authorization to iasca in association with WJ Weiser & Associates, Inc. to charge the amount indicated on the credit card provided. I am the authorized user of the credit card listed above and that the associated information entered (account holder name, account number, billing address, etc.) is accurate. I intend the act of selecting “I Agree” to be my legal signature to this agreement. If accepted for membership, I hereby agree to abide by the Constitution and Bylaws of the Illinois Ambulatory Surgery Center Association. Please sign with the email to which your application submission confirmation should be sent: Enter Security Code: 805312