Member Login

ASC Membership Application

For an application to be considered it must be filled out completely and the following supporting documents must be sent to the ASC National Office: curriculum vitae (CV), a copy of either your current licenses(s) or registration certificate(s). Your application must also include sponsor information.

Membership Type*


Please complete all information:

Items marked with an * are mandatory.
*Last Name:
*First Name:
*Middle:
*Degree:
*Date of Birth:
MM/DD/YYYY
*Gender:

Office Address

*Institution Name:
*Title/Department:
*Address 1:
Address 2:
Address 3:
*City:
*State Or Province:
*Country:
*Zip/Postal Code:
*Telephone Number:
111-222-333
Fax:
111-222-333
*Email:

Home Address

*Address 1:
Address 2:
Address 3:
*City:
*State Or Province:
*Country:
*Zip/Postal Code:
Telephone Number:
111-222-333
Fax:
111-222-333
Mail to be sent to: Office Address Home Address

Professional Organizations

Please check those related, professional organizations in which you are currently an active member:

AMA
ASCP
ASCT
CAP
CLMA
IAC
Pap Society
State Pathology Association
State/Regional Cytology Association
USCAP

None of the above

Sponsor

A sponsor can be a supervisor, lab director, department chief or an associate that can provide a reference for you.
*Name:
*Address:
*City:
*State Or Province:
*Country:
Zip/Postal Code:
Telephone Number:
111-222-333
Fax:
111-222-333
*Email:

Education of Applicant
Medical, Dental, or Veterinary School:
*Degree:
Date Received:
MM/DD/YYYY
Accredited Program:
Certification:
Dates of Attendance:
MM/DD/YYYY

Additional Training or Experience in Cytopathology

 

Resident, Fellow or Student Cytotechnologists
Training Completion Date:
MM/DD/YYYY
Name of Program Director:

I certify that the information contained in this application is true and complete to the best of my knowledge and belief. I acknowledge that I have received and read the Constitution and Bylaws of the Society, and I agree to be bound by their terms. I release from any liability all representatives of the Society for any statements made or actions taken in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and in connection with any expulsion or deletion from the rolls of membership or reapplication. I hereby release from any liability any and all individuals and organizations who provide information to the Society, in good faith and without malice, concerning my education and training and other qualifications for membership, and I hereby consent to the release of such information.

If you have a promo code, please enter it here:

Send supporting documents to:

Office of the Secretary-Treasurer
American Society of Cytopathology
100 West 10th Street, Suite 605
Wilmington, DE 19809
Telephone: (302) 543-6583
Fax: (302) 302-543-6597
asc@cytopathology.org