2025 Individual Membership Application

Individual Information

First Name
Last Name
Title
Address
City State Zip
Web Address
Phone
Email
Please provide a brief description of service (please note here if you have a center that has not opened)

Membership Fees

Membership fees are due upon joining. Renewals are pro-rated and billed for the annual January payment.

Were you referred by a member or partner?
(please enter the name)

The Importance of a PAC Contribution

The CASA PAC is a voluntary political organization that contributes to candidates for state office who share our philosophy and vision of the future of medicine. Political law and the CASA PAC Committee determine how your contribution is allocated. Contributions to PACs are voluntary and not limited to the suggested amounts.
PAC Contribution Rules: Corporate/Company can contribute $9,100 per calendar year. If an individual owns 50% or more of the contributing company, the individual’s personal contribution and the company’s contribution cannot exceed $9,100. PAC contributions can only be used for political purposes. These funds cannot be used to pay for lobbying efforts.
Contributions are not deductible for state or federal income tax purposes. Any contribution of $100 or greater will be publicly reported.

Donation

If your organization is prohibited from participating in the CASA PAC, you can still be involved by contributing to the CASA Advocacy Fund.
My organization would like to participate in:
CASA PAC
Advocacy Fund

Voluntary Contribution

 
 Other Amount: $

Code of Conduct for CASA Members

By submitting an application for membership or for renewal of membership, the Facility, Individual and/or Vendor acknowledges that it has reviewed the CASA Code of Conduct and Bylaws, and pledges, without reservation to adhere to the standards of practice and conduct set forth therein, with regard to the quality of ambulatory care provided and the management of all other aspects of the member’s operations as well as with regard to participation in the credentialing process itself. To review CASA’s complete Bylaws & Code of Conduct, please visit www.casurgery.org/bylaws.

I have read and agree to the Code of Conduct for CASA Members
(please intial)
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