MASA 2026 Facility Membership Form | Michigan Ambulatory Surgery Association

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URL

This field is for validation purposes and should be left unchanged.

First Name*

Last Name*

Email*

Enter Email

Confirm Email

Facility Name*

Facility Address*

Street Address

Address Line 2

City

State

ZIP Code

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Membership Level

Total

Billing Name*

Billing Address*

Street Address

Address Line 2

City

State

ZIP Code

Payment Method

Credit Card / Bank Transfer (ACH)

Check

Mail check to:

MASA
PO Box 150631
Grand Rapids, MI 49515

(please print confirmation email and send with check)

Credit Card*

2026 Facility Membership Form