ATSP Associate Membership Application

Association of Telemedicine Service Providers


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ATSP Membership Application

Applicant Information
Title	Dr. Mr. Mrs. Ms.

First name

Last name

Job title

Organization

Address line 1

Address line 2

City

State/province

Zip/postal code

Country

Telephone

E-mail

Fax

Web URL

Billing Information
Credit Card	After submitting your membership information on this page, an ATSP staff member will call you to take your credit card information over the phone. *ATSP only accepts Visa or MasterCard

Billing address
If the applicant's mailing & billing address are the same, go to About your business. If different, please complete billing address.

Billing address *if different from applicant info
Billing Address line 1

Billing Address line 2

Billing City

Billing State/province

Billing Zip/postal code

Billing Country

Membership level Please select a level of membership.
Membership

Annual dues

About your business Please complete the following as it applies to the purpose & practices of your business.
Industry type select one option that best describes your business	specify other

Product/services List information about the specific products or services marketed and/or manufactured by your business

Product/services categories select all that apply	Consultant services Electronic medical records Diagnostic/consultative service providers Education and/or training Home health care systems Network integrators Public relations Print publications Scopes, cameras & other devices Software Store-and-forward systems Telecommunication providers Telemedicine solution integrators Telemonitoring equipment Teleradiology & PACS Videoconferencing systems Web based solutions Other products or services

Number of employees who produce, market, or support telemedicine/e-health products and/or services:

I formally request application to the Association of Telehealth Service Providers (ATSP) for membership. I understand that privileges are limited to members. Distribution of any materials provided as a benefit of membership is strictly prohibited without the express consent of the ATSP. I understand that membership in the ATSP does not indicate or imply endorsement of any kind and is subject to final approval by the ATSP.

Association of Telehealth Service Providers
4702 SW Scholls Ferry Road
#400
Portland, Oregon 97225-2008 USA
Email
Tel 503.922.0988
Fax 315.222.2402