Membership Application

Thank you for your interest in becoming a member of AMSP – The premier national association for medical service providers in the healthcare technology industry. Active Membership requires that the Member be in a medical equipment service related field.

Please complete the following information and click the Submit button below.

if you wish, print and complete the form and email the completed form to:

Manny Roman
manny.roman@me.com
330-348-9304

* Indicates required field

Company *

Year Established *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Principal's Name *

First

Last

Title *

Phone Number *

Email *

Alternate Contact *

First

Last

Title *

Phone Number *

Email *

Do you have an AMSP Sponsor *

Yes No

Name of AMSP Sponsor *

TERMS AND CONDITIONS
1. All applications will be reviewed by the Executive Board and voted on by the membership
2. Upon approval of the application process, the prospective member must pay an Initiation Fee of $1,000.
3. Annual Dues in the amount of $1,500 will be prorated and due no later than the last day of the month in
which new member was approved.

Submit Your Application

amsp_associate_member_application.docx
File Size:	281 kb
File Type:	docx

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Application for AMSP Membership