Ambassador Program

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If you are interested in becoming an ASET Ambassador, please complete and submit the form below.
First Name: *
Last Name: *
Mailing Address: *
Ste/Apt/Floor/ect.
City: *
State: *
Zip Code: *
Email: *
Phone:
 

Presentation Information:
Please provide us below just a few details about your upcoming presentation. This information will help us determine if the Ambassador Program is successful.
 
Please note, the giveaway/promotional items can be costly to The Society, please only request what you will use.
Type of Audience:

Clear Selection
Anticipated Attendance (number):
Need by Date (for promotional material): *
Name and Description of Event:
City:
State:
Where did you learn about the Ambassador Program: *

Clear Selection
  Yes! Please notify me by email about special events, promotions, and other materials.





Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

ASET - The Neurodiagnostic Society, 402 East Bannister Road, Suite A, Kansas City, MO 64131-3019
(t) 816.931.1120 | (f) 816.931.1145 | (e) info@aset.org