APPLICATION FOR MEMBERSHIP
AMERICAN SOCIETY FOR CLINICAL LABORATORY SCIENCE
Name Date of application
Company (School) Department
Address (School) City State/Province/Postal Code
( ) ( )
E-Mail Address Telephone Fax
Home Address City State/Province/Postal Code
( ) 0 Check here if you want to receive your ASCLS mail at home
Home Phone
Have you ever been a member of ASCLS? ______ Yes ______ No Membership Number _______________________________
SCIENTIFIC ASSEMBLY
Please tell us which Scientific Assembly sections you would like to join. ASCLS’s Scientific Assembly sections provide an opportunity for members to network within their own scientific discipline. There is no additional fee for participation. (choose one primary and one secondary interest)
PRIMARY SECONDARY INTEREST CERTIFYING
AGENCY AND DESIGNATION:
__(01) __(01) biochemistry/urinalysis/ligand immuno-assay (4)
__NCAMLP __(a) CLS
__(b) CLT __(c) other
__(02) __(02) microbiology (5)
__AMT __(a) MT
__(b) MLT __(c) other
__(03) __(03) laboratory administration (6)
__ASCP __(a) MT
__(b) MLT __(c) other
__(04) __(04) immunology/immunohematology (7)
__HHS __(b) CLT
__(c) other
__(06) __(06) Histology (8)
__ISCLT __(a) RMT __(b) RLT __(c) other
__(07) __(07) hematology/hemostasis (9)
__Other:
POSITION (circle
one) (P)
Lab Director (Admin) (N)
Lab manager (A)
Tech. supervisor (M)
Staff Technologist (CLS) (4)
Staff Technician (CLT) (t) Phlebotomist (6)
Laboratory Assistant (I)
Faculty Member/Instructor (K)
Program Director (L)
Consultant (U)
Inspector/Surveyor (2)
Marketing/Sales (J)
Other SPECIALTY AREA (circle one) Quality
Assurance Control Proficiency
Testing Infection Control Safety/HAZ
MAT Total
Quality Management CLIA
Compliance Laboratory
Utilization Laboratory
Reimbursement Lab
Information Systems Risk
Management (Facility Wide) Patient/Physician
Services Research Author/Reviewer
__(09) __(09) industry
__(10) __(10) education
__(12) __(12) phlebotomy
__(13) __(13) cytotechnology
__(14) __(14) consultant
__(15) __(15) inspector/surveyor
_______________________________________________________________________________________________________________________________________
Please assist ASCLS
in collecting the following voluntary statistics to provide analysis of
professional trends:
Employment
Status:__FT __PT __STU __UNEM
__Retired Highest Degree: __H.S. __Assoc.
__Bach. __Masters __Ph.D.
Year
of Birth: ___________ Sex: __F __M
SS#___________________________________
Race:
(please circle one) Caucasian / American Indian / Alaskan Native
/ Asian/Pacific Islander / African American /
Hispanic / Other
Contributions
or gifts to ASCLS and ASCLS/PAC are not deductible as charitable contributions
for federal income tax purposes.
However dues payments may be deductible by members as an ordinary
business expense. ASCLS estimates that
9% of your dues will be spent on lobbying, and therefore this portion will not
be deductible on your federal income tax return.
Please complete and send
this application with your payment to our lockbox:
ASCLS, P.O. Box 79154,
Baltimore, MD 21279-0154 Phone: 301-657-2768 Fax: 301-657-2909
ASCLS Membership
Categories and Eligibility Requirements
(ASCLS membership is from the date of payment to the next July 31.)
PROFESSIONAL (full voting privileges) is open to all persons certified or engaged in the practice and/or education process of the clinical laboratory science, including those with an active interest in supporting the purposes and goals of this Society. Membership benefits are dependent on level of membership:
PROFESSIONAL I includes basic benefits plus the award winning journal, CLS.
PROFESSIONAL II includes basic benefits only.
National Dues: Professional I - $80; Professional II - $55; plus
State Dues: (see attached schedule)
COLLABORATIVE (Non-voting
privileges) is available to any individual who currently holds membership in
any other health related national organization AND HAS NEVER BEEN A MEMBER OF ASCLS.
National Dues only: $25
FIRST YEAR PROFESSIONAL* (full voting privileges) Open to persons who have graduated within the last twelve months from an accredited program in laboratory science. Prior student membership with ASCLS is not a prerequisite. This membership status is valid for only one year to assist recent graduates. After one year in this category, members are upgraded to Professional membership.
National Dues: $40.00 State Dues: (see schedule below)
STUDENT*(non-voting privileges) Open to persons enrolled in a structured program of training or academic instruction in clinical laboratory science, or to full-time graduate students in related science area.
National Dues:
$25.00 States Dues: (see
schedule below)
*Persons residing in foreign countries are not eligible for these categories--only the Professional categories.
I wish to join ASCLS as a
________________________________ member.
(Students, please list your
expected date of graduation: _________
Mo/Yr.)
Membership dues: ________
+ State dues: _______ =
Total payment enclosed
______________
Method of Payment: (U.S.
Funds Only)
__ Check (payable to ASCLS) __ Visa
__ MasterCard __Amex
Exp.
date______________________ Card
#______________________________________
Name on card
_______________________________ Signature_________________________________
STATE DUES SCHEDULE
|
|||
Professional I & II
|
Student
|
||
|
CA |
$25 |
FL, HI, IL, IN, IA, LA, MA, NE, NH, NJ, NY, NC, PR, RI, VA, WI |
$5 |
|
CO, NY |
$20 |
AL, MS |
$4 |
|
TX |
$18 |
OH, OK |
$3 |
|
FL, HI, LA, MI, MN, MO, NC, NE, NJ |
$15 |
AZ, CT, GA, KY, MI, NV, SC, TN, UT, WV |
$2 |
|
AL, AK, AZ, AR, CT, GA, ID, IL, IN, IA, KS, KY, MA, MS, MT, NV, NH, OH, OK, OR, PA, PR, RI, SC, SD, TN, UT, VA, WA, WI, WV, WY |
$10 |
STATES NOT LISTED |
$0 |
|
DC, MD |
$6 |
|
|
|
DE, ME, NM, ND, VT |
$5 |
|
|