ASC Membership Application

For an application to be considered it must be filled out completely and the following supporting documents must be uploaded with your application below: curriculum vitae (CV), a copy of either your current licenses(s) or registration certificate(s). Your application must also include sponsor information.

 

Please complete all information:
Items marked with an * are mandatory.

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Required Supporting Documents
Completing your application online requires uploading the following as either .PDF or .DOC files:

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Office Address

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Home Address

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Professional Organizations
Please check those related, professional organizations in which you are currently an active member:

  AMA
ASCP
ASCT
CAP
CMLA
IAC
Pap Society
State Pathology Association
State/Regional Cytology Association
USCAP
None of the Above

Education of Applicant

 
 
 
 
 
 
 

Resident, Fellow or Student Cytotechnologists

 
 

Sponsor Information
Your sponsor must be actively involved in cytopathology but does not need to be an ASC Member. A sponsor can be a supervisor, lab director, department chief or an associate that can provide a reference for you.

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Payment Information
If paying by Check or Purchase Order (PO) Number, please disregard all credit card information fields.

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I certify that the information contained on this application is true and complete to the best of my knowledge and belief. I agree to be bound by the Bylaws of the Society. I release from any liability all representatives of the Society for any statements made or actions taken in good faith and without malice in connection with evaluating my application and my
credentials and qualifications, and in connection with any expulsion or deletion from the rolls of membership or reapplication. I hereby release from any liability all individuals and organizations that provide information to the Society, in good faith and without malice, concerning my education and training and other qualifications for membership, and I hereby consent to the release of such information.

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