Membership information | Roster

APPLICATION FOR SUPPLIERS ALLIANCE MEMBERSHIP
IN THE AMERICAN LITHOTRIPSY SOCIETY

Print, complete, and mail this form with your payment to the address at the bottom of the page.

1. I, the undersigned, herewith make application for Suppliers Alliance Membership in The American Lithotripsy Society.

Company Name: _______________________________________________________________________

Office Address: _______________________________________________________________________________

City: ________________________________________ State:_____________ Zip:_______________________

Country: __________________________________________ Email Address: __________________________

Office Telephone: _________________________________ Fax:__________________________

Company Officials/Officers:

Name: ____________________________________________ Title: ________________________________

Name: ____________________________________________ Title: ________________________________

Name: ____________________________________________ Title: ________________________________

Corporate Contact: __________________________________ Telephone: ______________________________

2. Description of your company: ________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

3. Description of SWL products: ________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

4. Description of SWL Services: ________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

5. Location of Branch and/or Service Offices: _______________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

6. is this company a subsidiary or a parent corporation to other companies? If so, whom?

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

7. Number of Employees: _________________________

Number of SWL Related Employees: ________________________

8. Please include a copy of your company's most recent annual report and descriptive product/service brochures.

9. List company personnel to be included in the ALS Directory of Members. Designate a senior executive as "Official Representative." Designate an "Official Correspondent" for company dealing with the American Lithotripsy Society.

Name _____________________________________ Title ______________ Telephone ___________________

Name _____________________________________ Title ______________ Telephone ___________________

Name _____________________________________ Title ______________ Telephone ___________________

Submitted by: _______________________________________

 Signature ____________________________________________________  Date ___________________
 Title ______________________________________  

 
AMERICAN LITHOTRIPSY SOCIETY
SUPPLIERS ALLIANCE MEMBERSHIP FEE SCHEDULE

 

Annual Membership Fee: ..........................$1,500

Total Amount Enclosed: $_____________ (Make check payable to "American Lithotripsy Society.")

Send Application and Fee to:

American Lithotripsy Society
305 Second Avenue, Suite 200 Waltham, Massachusetts 02451
Telephone: 781-
(895-9098; Fax: 781-895-9088


FOR OFFICE USE ONLY

Date Received: ______ By: __________________

Information Received: _________________Application

______________ Membership Fee

Date Approved:____/____/____ Date Acknowledgment Sent: ____/____/____

Comments: