Anesthesia Administrators of Texas

2005 Membership Application/Renewal

 

 

Type of application:     ____ New Member      ____ Renewal

 

Name __________________________________ Title ___________

 

Organization Name _______________________________________

 

Type of Entity (please check one)

          □ Anesthesiology Practice    □ Multispecialty Group

□ Billing Company/MSO        □ Academic Program

□ Other ____________________________________

 

Address ________________________________________________

 

City, State, Zip ___________________________________________

 

Phone _____________________ Fax ________________________

 

E-mail address __________________________________________

 

Subspecialties (please check all that apply):

□ Acute Pain   □ Chronic Pain   □ OB   □ Office Based   □ CV

 

Referred By: ____________________________________________

 

Preferred Method of Communication:

□ US Mail   □ Email       □ Fax

 

Do you want your contact information posted on the AAT Member-Only Web Community?                   □ YES        □ No

 

Please return completed application with your check for $50 to:

 

Anesthesia Administrators of Texas

Donita Billings, Treasurer

4129 Crescent Dr.

Flower Mound, TX  75028