SOUTHERN ASSOCIATION OF CYTOTECHNOLOGISTS, INC.

APPLICATION FOR MEMBERSHIP

(Please print, write or type in a manner that is legible!  Much Thanks)

NAME: _______________________________________________________________________________

                (Last)(First)       (MI)

Nickname/"Go by":______________________________________________________________________

E-mail ADDRESS: ____________________________________________________________________

Alternate e-mail address: :_________________________________________________________________

                                             

MAILING ADDRESS: ___________________________________________________________________

(Street Name and Number)

_____________________________________________________________________________________

(City)(State)(Zip)

TRAINING/EXPERIENCE:

Student at:____________________________________________________________________________

Program Directorr _________________________________________ Graduation Date ________________

Current Employment: FT, PT, PRN (Circle One) at________________________________________________

_____________________________________________________________________________________   

MD/other:_____________________________________________________________________________

ASCP Board Registration: (Students: I am scheduled to take the exam on: __________________________

CT(ASCP) ____________________________________________________________________________

DateRegistration Number

SCT(ASCP) ___________________________________________________________________________

DateRegistration Number

Other credentials ______________________________________________________________________

DateRegistration Number

    

STATEMENT OF INTENT:  I hereby make application ffor membership in the SAC and have enclosed

my dues payment in the amount of $25.00.

_____________________________________________________________________________________

Signature of applicantDate

Mail application and dues payment to:

Pamela L. Schubert

Secretary SAC

1900 Richard Jones Road

Townhouse #V-2

Nashville, Tn.  37215

Send questions/comments to:

plschubert@bellsouth.net

For Sexcretary:

Date Received _____________________    Mail - Meeting - Other

Check # __________________________   Amount $ _____________

In-Area/Active: ____________________________________________

Out-of-area/Associate:______________________________________

Notes: __________________________________________________