Name ______________________________________________ 
Address ____________________________________________
____________________________________Zip ____________
ASCLS Membership # ____________Year Joined _________
Place of Employment _________________________________
Address ____________________________________________
____________________________________Zip ____________
Position ____________________________________________

Continuing Education Program Applied for :
Title _______________________________________________
Location ____________________________________________
Date: from ____________ to ___________ Tuition __________
Sponsored By ________________________________________
Address _____________________________________________
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
Send completed application to:
Nellie Bering
4000 Gypsy Lane, Apt 342
Philadelphia PA 19129