2015 INSTITUTIONAL MEMBER APPLICATION

2015 INSTITUTIONAL MEMBER APPLICATION ASET The Neurodiagnostic Society 402 E. Bannister Road, Suite A Kansas City, MO 64131 Tel: 816.931.1120 * Fax: 816.931.1145 * info@aset.org To apply for membership, return completed application with payment by mail or by fax. ASET membership is from January through December. First-year dues are pro-rated based on join date. For Institutions joining October through December, membership runs through December of the following year. Section I: Membership Category/ Chapter Affiliation INSTITUTIONAL MEMBERSHIP - Health care delivery or educational institutions which employ or educate neurodiagnostic technologists. Dues include membership for one primary billing contact, and up to four additional employees. EACH ADD-ON EMPLOYEE - Institutions may enroll more than the five employees included in the base Institutional member dues at the per employee add-on rate. Please check ASET membership type: INSTITUTIONAL MEMBERSHIP Jan March $435 US $485 Non-US April June $326 US $364 Non-US July Sept $218 US $243 Non-US Oct Dec $435 US $485 Non-US EACH ADD-ON EMPLOYEE $75 US $85 Non-US $56 US $64 Non-US $37 US $43 Non-US $75 US $85 Non-US INSTITUTIONAL/CORPORATE CHAPTER MEMBERSHIP Chapters are local, state or regional neurodiagnostic organizations that have been officially chartered by ASET. They provide continuing education and timely communication, allowing your institution to stay abreast of developments in the neurodiagnostic profession in your locality. Joining one or more chapters is optional. Institutional/Corporate Chapter membership applies only to the Institution and may not carry with it the same rights and privileges as individual chapter membership. Visit the chapter websites for information on member benefits and privileges. If your institutional employees would like to affiliate directly with a chapter, please instruct them to file an individual member application directly with the chapter. Contact information and links to each chapter s websites are posted at www.aset.org (click on Chapters under the Membership tab drop-down menu). One hundred percent of chapter dues collected by ASET are rebated to the respective chapters.for your institution to also join a chapter(s), please select from the following and include the amount of chapter dues in your total payment: Please check Chapter membership type: Jan March April June July Sept Oct Dec *ISETT (Indiana) $30 $23 $15 $30 * ISETT Institutional dues per employee member Section II: Applicant Information Organization Name: Business Mailing Address: City: State/Province: Business Phone: [ ] Zip/Postal Code: Country: Business Fax: [ ] Number of Neurodiagnostic Technologists Employed by Institution: Reference Code (if applicable): How did you hear about ASET? Hospital Administration Co-worker ABRET Tradeshow Advertisement Direct Mail Internet Broadcast Email Social Media (Specify) Other (Specify) Section III: Primary Billing Contact Information Please identify the Institutional employee to serve as the primary billing contact. This individual will receive the Institutional member subscription to The Neurodiagnostic Journal and the ASET newsletter, and will receive an individually-assigned ASET ID number, member log-in, and password for accessing the Members Only section of the ASET website and to qualify for member rates on ASET training courses, products and services. Primary billing contacts have voting privileges and may serve on ASET committees, but are not eligible to serve as a trustee or officer of the Society (unless they upgrade their membership to the Active member class). Last Name: First Name: E-Mail: * Required field. Representative s log-in and password to access the Members Only pages of the ASET website will be automatically assigned and e-mailed to him/her upon approval of application. Representative may change his/her

2 year Associates Degree BA BS MA MS MEd PhD Other Membership information is included in ASET s searchable on-line membership directory. However, we recognize the importance of employee privacy and provide employees with options relating to their listing. If no option is selected, membership information will be included in the searchable member directory. Information as noted above can be included in the on-line member directory. Information is not to be included in the on-line member directory. Section IV: Employee Member Information In addition to the Primary Billing Contact, up to four more employees may be enrolled under an Institutional membership at no additional cost. Each employee enrolled will receive an individual subscription to The Neurodiagnostic Journal and the ASET newsletter, and will receive an individuallyassigned ASET ID number, member log-in, and password for accessing the Members Only section of the ASET website and to qualify for member rates on ASET training courses, products and services. Institutional employee members have voting privileges and may serve on ASET committees, but are not eligible to serve as a trustee or officer of the Society (unless they upgrade their membership to the Active member class). In the event of employment changes and/or new hires, an Institution may add employees to its Institutional membership, transfer an employee s membership to another employee, or inactivate an employee s membership, at any time throughout the year simply by calling the ASET Executive Office EMPLOYEE 1: 2 year Associates Degree BA BS MA MS MEd PhD Other

EMPLOYEE 2: 2 year Associates Degree BA BS MA MS MEd PhD Other EMPLOYEE 3: R. EEG T. R. EP T. RPSGT CNIM R.NCS.T. CLTM Other 2 year Associates Degree BA BS MA MS MEd PhD Other

EMPLOYEE 4: 2 year Associates Degree BA BS MA MS MEd PhD Other Section V: Add-on Employee Member Information Institutional members may enroll more than the five employees covered by the base Institutional member dues at the add-on employee rate listed herein. There is no limit to the number of employees that an Institutional member may enroll. Each additional employee enrolled will receive an individual subscription to The Neurodiagnostic Journal and the ASET newsletter, and will receive an individually-assigned ASET ID number, member login, and password for accessing the Members Only section of the ASET website and to qualify for member rates on ASET training courses, products and services. For each add-on employee, please complete the following information. Please duplicate this section and attach to this application if more than one addon employee is being enrolled. Add-on Employee 1:

2 year Associates Degree BA BS MA MS MEd PhD Other Section VI: Communication Consent Federal regulations by the FCC require ASET to have permission before we can communicate with Institutional member employees via fax or e-mail about important products, programs or services. I hereby give ASET this day of, 20 written permission to send notices, advertisements, announcements, brochures, invoices and other information from ASET via facsimile and /or e-mail at the numbers and address shown herein. This permission will have no date of expiration.* Signature Date On occasion, ASET may rent member mailing addresses and e-mail addresses to its business associates and third-parties for marketing purposes. If you would like to be included in these communications, please check each item that applies:* Business associates/third-party mail Business associates/third-party e-mail * Institutional employee members may opt-out from receiving communications from ASET and/or its business associates in the future by logging on to the Members Only section of the ASET website and changing their communication preferences. Section VII: Payment Information Check or Money Order payable to ASET The Neurodiagnostic Society [payment must be in US dollars drawn on a US bank] American Express Discover MasterCard Visa Name on Card Account No --- Expiration Date / Billing Zip Code CID Month Year Cardholder Signature $ ASET General Operations Fund [optional] $ TOTAL ENCLOSED** made payable to ASET The Neurodiagnostic Society [Federal Tax ID#74-1553534] In addition to dues, enclosed is $ as a donation to the ASET Foundation General Fund (Federal Tax ID # 77-0644963) Please include do not include our Institution s name in the donation acknowledgment. Make foundation donations payable to the ASET Foundation. Gifts made to the ASET Foundation are deductible as a charitable contribution in the year in which they are given. (Federal Tax ID# 77-0644963) **ASET estimates that of the non-deductible portion of the 2015 Institutional member base dues, the portion that is allocable to lobbying activities, is $82.50. Annual subscriptions to The Neurodiagnostic Journal and ASET News are included with your membership and may not be deducted from dues. Dues portions allotted for publications are $10 for the newsletter and $75 for the journal. ASET s FEIN is 74-1553534. A member may resign or cancel their membership at any time by submitting their resignation in writing to info@aset.org. Membership dues are non-refundable.