1419 Superior Avenue Suite #2

Newport Beach, CA 92663

Phone: 949-645-6665,  Fax: 949-645-6784

E-mail: ascbsweb@yahoo.com      Web: www.ascbs.us

Name___________________________________________________

Address________________________________________________

City___________________________________________________

State__________________________________________________

Zip code & Country______________________________________

Phone #:__________________________________________________

FAX #:_____________________________________________

E-Mail Address ____________________________________________

Website Address ___________________________________________

Initiation Fees for each Type of Membership (see requirements)

Member $300.00  ___________________________

Associate Fellow $300.00_____________________

Fellow $1,800.00____________________________

Life Member or Fellow $2,800.00________________

I have performed ______________(number) of cosmetic breast surgeries and have included my Curriculum Vitae for review.

Enclose a check payable to A.S.C.B.S. or submit credit card payment below:

We are only able to accept MasterCard or Visa .

Credit card number: ___________________________________  Expiration Date: _______________

MasterCard   ___________   Visa  ___________________ 

Name on the credit card ______________________________________

Signature of cardholder:________________________________________

On the membership certificate my name should read: _________________________________________________________

Signed:_________________________________________________