2018 INSTITUTIONAL MEMBER APPLICATION

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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.

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: Jan – March _{Join Date} April – June _{Join Date} July – Sept _{Join Date} Oct – Dec _{Join Date}

INSTITUTIONAL MEMBERSHIP

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$500US

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$560Non-US

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$375US

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$420Non-US

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$250US

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$280Non-US

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$500US

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$560Non-US

EACH ADD-ON EMPLOYEE

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$86 US

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$98Non-US

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$65US

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$74Non-US

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$43US

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$49Non-US

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$86US

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$98Non-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 _{Join Date} April – June _{Join Date} July – Sept _{Join Date} Oct – Dec _{Join Date}

ISETT (Indiana) – dues per employee member

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$30

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$23

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$15

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$30

Organization Name: _________________________________________________________________________________________________________ Business Mailing Address: ___________________________________________________________________________________________________ City: ________________________ State/Province: _______________ Zip/Postal Code: _______________ Country: ______________________ Business Phone: (_______)_____________________________ Business Fax: (_______)____________________________________ Number of Neurodiagnostic Technologists Employed by Institution: ________________________

How did you hear about ASET?

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Hospital Administration

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Co-worker

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ABRET

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Tradeshow

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Direct Mail

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Internet

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Broadcast Email

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Social Media (Specify) ________________

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Other (Specify) _____________________________________

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: __________________________________ Middle: _________________ 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 log-in and password at any time thereafter.

Check appropriate credentials, if any:

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R. EEG T.

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R. EP T.

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RPSGT

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CNIM

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R.NCS.T.

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CNCT

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CLTM

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CAP

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Other __________________________________

Section I: Membership Category/ Chapter Affiliation

Section II: Applicant Information

ASET – The Neurodiagnostic Society

402 E. Bannister Road, Suite A

Kansas City, MO 64131

Tel: 816.931.1120 * Fax: 816.931.1145 * [email protected]

2018 INSTITUTIONAL MEMBER APPLICATION

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Check appropriate degrees, if any:

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2 year Associates Degree

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BA

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BS

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MA

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MS

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MEd

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MHA

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PhD

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Other __________________________________ ASET-CEUs and statistical data information:

Date of Birth _______/_______/_______

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Male

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Female

(Note: This information is for ASET internal use only for matching and maintaining individual ASET-CEU records. It is NOT published.)

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.

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Information as noted above can be included in the on-line member directory.

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Information is not to be included in the on-line member directory.

Optional Information: ASET Interest Section Forums, a member-only benefit, are interactive discussion forums where members may share tips and resources, ask questions of one another and help colleagues solve problems or gain new insight into issues. Interest Sections also meet at the ASET Annual Conference for face-to-face networking. From the list below, please select as many sections in which you have an interest and with which you would like to be identified. ASET’s searchable on-line membership directory includes the ability to search by Interest Section members. If you have provided permission to have your information included in the on-line membership directory, your Interest Section selections will be included in that search feature. Entrepreneur

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Acute/Critical Care

Neurodiagnostics

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workplace Computers in the

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IONM

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Neurofeedback

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Technologists as Entrepreneurs

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Ambulatory Monitoring

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CPT Codes

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MEG

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New Technologies & Research

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Autonomic Testing

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Dept Managers

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NCS

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Pediatrics & Neonatology

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Clinical EEG

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Epilepsy Monitoring

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Neurodiagnostic Education

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PSG/Sleep Technology

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 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. 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:

Last Name: ____________________________________________ First Name: _______________________________ Middle: _________________ Mailing Address if different than Institution mailing address:

Street Address: ____________________________________________________________ City: _________________________________________ State/Province: ___________________________________ Zip/Postal Code: _________________________ Country: ______________________ Business Phone: (_______)___________________________ Home Phone: (_______)__________________________________________

E-Mail: ___________________________________________ * Required field. Employee log-in and password to access the Members Only pages of the ASET website will be automatically assigned and e-mailed to the employee upon approval of application. Employee may change his/her log-in and password at any time thereafter.

Check appropriate credentials, if any:

 R. EEG T.  R. EP T.  RPSGT  CNIM  R.NCS.T.  CNCT  CLTM  CAP  Other __________________________________ Check appropriate degrees, if any:

 2 year Associates Degree  BA  BS  MA  MS  MEd MHA  PhD  Other _____________________________________ ASET-CEUs and statistical data information:

Date of Birth _______/_______/_______

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Male



Female

Membership information is included in ASET’s searchable on-line membership directory. However, we recognize the importance of employee privacy and provide options relating to their listing. If no option is selected, employee’s name will be included in the searchable member directory.



Employee information as noted above can be included in the on-line member directory.



Employee information is not to be included in the on-line member directory.

Optional Information: ASET Interest Section Forums, a member-only benefit, are interactive discussion forums where members may share tips and resources, ask questions of one another and help colleagues solve problems or gain new insight into issues. Interest Sections also meet at the ASET Annual Conference for face-to-face networking. From the list below, please select as many sections in which you have an interest and with which you would like to be identified. ASET’s searchable on-line membership directory includes the ability to search by Interest Section members. If you have provided permission to have your information included in the on-line membership directory, your Interest Section selections will be included in that search feature.

Acute/Critical Care

Neurodiagnostics  workplace Computers in the IONM  Neurofeedback  Technologists as Entrepreneurs

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 Ambulatory Monitoring CPT Codes  MEG  New Technologies & Research

Autonomic Testing Dept Managers NCS  Pediatrics & Neonatology

Clinical EEG Epilepsy Monitoring  Neurodiagnostic Education PSG/Sleep Technology EMPLOYEE 2:

Street Address: ____________________________________________________________ City: _________________________________________ State/Province: ___________________________________ Zip/Postal Code: _________________________ Country: ______________________ Business Phone: (_________)__________________________ Home Phone: (_______)_____________________________________________ E-Mail: ___________________________________________ * Required field. Employee log-in and password to access the Members Only pages of the ASET website will be automatically assigned and e-mailed to the employee upon approval of application. Employee may change his/her log-in and password at any time thereafter.

Check appropriate credentials, if any:

Date of Birth _______/_______/_______

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Male

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Female

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Check appropriate credentials, if any:

Date of Birth _______/_______/_______

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Male



Female

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Check appropriate credentials, if any:

Date of Birth _______/_______/_______

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Male



Female

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Clinical EEG Epilepsy Monitoring  Neurodiagnostic Education PSG/Sleep Technology

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 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.

For each on employee, please complete the following information. Please duplicate this section and attach to this application if more than one add-on employee is being enrolled.

Add-on Employee 1:

Street Address: ____________________________________________________________ City: _________________________________________ State/Province: ___________________________________ Zip/Postal Code: _________________________ Country: ______________________ Business Phone: (_________)__________________________ Home Phone: (_______)_____________________________________________

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E-Mail: ___________________________________________ * Required field. Employee log-in and password to access the Members Only pages of the ASET website will be automatically assigned and e-mailed to the employee upon approval of application. Employee may change his/her log-in and password at any time thereafter.

Check appropriate credentials, if any:

Date of Birth _______/_______/_______

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Male



Female



Clinical EEG Epilepsy Monitoring  Neurodiagnostic Education PSG/Sleep Technology

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:*

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Business associates/third-party mail

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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.

$_______ ASET Membership Dues $_______ ASET Chapter Dues (optional)

$_______ Donation to ASET General Operations Fund (optional)

$_______ Donation to ASET Foundation (optional) - 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). Please



include

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do notinclude my name in the donation acknowledgment.

$ _______ Total amount made payable to ASET – The Neurodiagnostic Society or to be charged** (Federal Tax ID#74-1553534) Payment Method:

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Check or Money Order payable to ASET – The Neurodiagnostic Society (payment must be in US dollars drawn on a US bank)

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American Express

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Discover

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MasterCard

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Visa

Name on Card: _________________________________________________________________________________________________ Account No: ___________________________________________________________________________________________________ Expiration Date: ______________________

Month / Year Billing Zip Code: _____________________ CID: ________________________

Cardholder Signature:____________________________________________________________________________________________

**ASET estimates that of the non-deductible portion of the 2018 Institutional member base dues, the portion that is allocable to lobbying activities, is $157.50. 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 $107 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 [email protected]. Membership dues are non-refundable.

Section VII: Payment Information

Section VI: Communication Consent