APPLICATION FOR
CONTINUING EDUCATION ASSISTANCESHIP
FOR MEDICAL TECHNOLOGY

Name ____________________________________________________________________________
Address __________________________________________________________________________
_____________________________________________________________Zip _________________
ASCLS Member # ________________________ Year Joined ______________
               NOTE: If you do not know your ASCLS member number, contact info@ascls-pa.org

Place of Employment (or Previous Employment): _____________________________________________
Address ____________________________________________________________________________
____________________________________________________________________Zip ____________
Position ____________________________________________

Continuing Education Program Applied for :
Title _______________________________________________________________________________
Location ________________________________  Date: from _______________to __________________
Program Sponsored By __________________________________________________________________

Reason for Desiring to Attend ____________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

I understand that within two (2) weeks of the end of this course, I must submit  proof of successful completion of the course (copy of transcript, certificate or statement from instructor) to the Society. In the event that I have not completed the course satisfactorily,
I promise to submit a check for the amount received.

Signature of applicant  ____________________________________________       Date: _________________________
Send completed application to:  Nellie Bering
                                                         4000 Gypsy Lane,  #342
                                                         Philadelphia PA 19129