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