ASA of PA State Office
1081 Pebble Court
Mechanicsburg, PA 17050

Office:  717-761-4508

CLINIC SANCTION

As a condition of obtaining this sanction, the above organization agrees to provide adequate insurance coverage and employ instructors who will provide the highest quality education.

The approved form must be displayed at the clinic in a conspicuous place.

Complete all information and mail with check made payable to "ASA of PA" to: 

ASA of PA, 1081 Pebble Court, Mechanicsburg, PA 17050

FEE:  $75

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Sponsoring Organization *
Contact Person *
First Name
Middle
Last Name
Address *
Address Line 1
Address Line 2
City
State
Postal Code
Phone*
Secondary Phone
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Type of Clinic *
Date of Clinic*
Location (City) where Clinic will take place: *
Facility being used: *
Division/Classification *