EXTENDED ASCLS MEMBERSHIP

Just a quick note to let you know that if you join ASCLS (our National parent organization) anytime before July 31, 2012, you will receive a membership until July 31, 2013.  Your membership comes with 6 hours of free CE, discounts for meetings, and many more fabulous perks.  Your membership dues are used to keep the society running and to also fund our lobbyist in Washington, DC, who works very hard to advocate on our behalf on issues affecting the laboratory.  If you would like to get more membership information, or to join ASCLS, please contact Wes Williamson, our current ASCLS-TN President, at twes_ww@yahoo.com.  A copy of the membership form is shown below.  Thanks so much for your continued support of MSCLS!

APPLICATION FOR MEMBERSHIP

AMERICAN SOCIETY FOR CLINICAL LABORATORY SCIENCE

First Name Last Name Date of application

Home Address City State/Province/Postal Code Country

( ) Receive ASCLS mail at:

Preferred Phone

Company (If Student, skip this line) Department

Address (If Student, Permanent address) City State/Province/Postal Code Country

( ) ( )

Preferred E-Mail Address Telephone Fax

Have you ever been a member of ASCLS? ______ Yes ______ No Membership Number _______________________________

□ home  business address  permanent address

Please complete and send this application with your payment to our lockbox:

ASCLS, P.O. Box 15330, Wilmington, DE 19886-5330

Phone: 202-367-1174 Fax: 202-367-2174

For fastest service, join online at

http://www.ascls.org/membership/index.asp.

CERTIFICATION AGENCY - Check all

credentials obtained as listed by each cert.

agency.

BOC

__MLS __MLT __other___

AMT

__MT __MLT __other___

HHS

Other:

___CLT __other_____

POSITION -circle one

Lab Director (Admin)

Lab Manager

Tech. Supervisor

Staff Technologist (MLS)

Staff Technician (MLT)

Phlebotomist

Laboratory Assistant

Faculty Member/Instructor

Program Director

Consultant

Inspector/Surveyor

Marketing/Sales

Other________________________

SCIENTIFIC ASSEMBLY

The ASCLS Scientific Assembly sections provide an

opportunity for members to network within their own

scientific discipline. There is no additional fee for

participation. Please choose one primary and one

secondary interest.

PRIMARY SECONDARY INTEREST

__ __ chemistry/urinalysis

__ __ microbiology

__ __ laboratory administration

__ __ immunology/immunohematology

__ __ histology/cytology

__ __ hematology/hemostasis

__ __ generalist/public health

__ __ industry

__ __ education

__ __ phlebotomy/POC

__ __ molecular bio/genetics

__ __ consultant

__ __ regulatory affairs/quality mgmt.

Please assist ASCLS in collecting the following voluntary statistics to provide demographics for grants:

Employment Status

: __FT __PT __STU __Unemployed __Retired Highest Degree: __H.S. __Assoc. __Bach. __Masters __Ph.D.

Year of Birth

: ___________ Sex: __F __M

Race: (

please circle one) Caucasian / American Indian / Alaskan Native / Asian/Pacific Islander / African American / Hispanic / Other___

ASCLS Membership Categories and Eligibility Requirements

(

(All Membership Categories eligible for

ASCLS membership is from the date of payment to the next July 31.)Certification Maintenance Program . see CE Options below)

STATE DUES SCHEDULE

Professional I & II Student

CA $25 CT, FL, HI, IL, IN, IA, LA, MA, MI, MS, NE, NH, NJ, NM,

NC, OH, PR, RI, SC, SD, TN, VA, WI

$5

CO, NY $20 AL $4

TX $18 OK $3

AK, AZ, FL, HI, LA, MN, MO, MT, NC, NE, NJ, NV, OH, SD,

TN

$15 GA, KY, UT, WV $2

$12 STATES NOT LISTED $0

AL, AR, CT, GA, ID, IL, IN, IA, KS, KY, MA, MI, MS, NH, OK,

OR, PA, PR, RI, SC, UT, VA, WA, WI, WV, WY

$10

& II

CA - $0, MN - $0, NY - $0, TX - $9, MD $6 CO - $10, OH - $10

DE, ME, NM, ND, VT $5

*First Year Professional (state dues schedule same as Professional Iexcept for the states listed below)

$55 Certification Maintenance CE Package -- 12 contact hours of online CE from MediaLab

$95 Certification Maintenance Plus CE Package -- unlimited online CE from MediaLab

I, ____________________________________________, wish to join ASCLS as a (please circle one) Professional I /

Professional II / First Year Professional / Collaborative / Student member.

(

Students, please list your expected date of graduation: _________ Mo/Yr.)

My mentor/recruiter is: Name__________________________________ ASCLS Member No.___________

Membership dues: ________+ State dues: _______ + CE package: ______ = Total payment enclosed __________

Method of Payment: (U.S. Funds Only)

__ Check (payable to ASCLS) __ Visa __ MasterCard __Amex

Exp. date______________________ Card #______________________________________

Name on card _______________________________ Signature_________________________________

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.

PROFESSIONAL

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:

(full voting privileges) is open to all persons certified or engaged in the practice and/or education process of

PROFESSIONAL I

includes basic benefits plus the award winning journal, CLS.

PROFESSIONAL II*

National Dues: Professional I - $99; Professional II - $78

includes basic benefits only.plus State Dues: (see attached schedule)

COLLABORATIVE*

related national organization

National Dues only: $45

(Non-voting privileges) is available to any individual who currently holds membership in any other healthAND HAS NEVER BEEN A MEMBER OF ASCLS.

FIRST YEAR PROFESSIONAL*

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: $45 plus State Dues

(full voting privileges) Open to persons who have graduated within the last twelve months

STUDENT

clinical laboratory science, or to full-time graduate students in related science area.

National Dues: $25.00 plus States Dues:

*Persons residing outside the U.S. are not eligible for these categories--International practitioners must join as Professional I.

*(non-voting privileges) Open to persons enrolled in a structured program of training or academic instruction in

CE Options Available with Membership

Go to http://www.ascls.org/?page=Edu_CMM for more information.