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
Sponsoring Organization *Contact Person *
Address Line 1
Address Line 2
Type of Clinic *
Date of Clinic*
Location (City) where Clinic will take place: *Facility being used: *Division/Classification *