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ASA OF PA Clinic Sanction Form

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, 6449 Snavely Court, Harrisburg, PA 17111-4566

FEE:  $75


Sponsoring Organization *Contact Person *

First Name


Last Name

Address *

Address Line 1

Address Line 2



Postal Code


Secondary Phone


Type of Clinic *

Date of Clinic*

Location (City) where Clinic will take place: *Facility being used: *Division/Classification *