ASA of PA
Clinic Sanction Form
Type in the information, All Fields are required.

Name of Sponsoring Organization:   Address:  
Contact Person:   City:  
Contact Telephone:   Zip Code:  
Secondary Phone:    Email:   

The above mentioned organization requests a sanction to conduct a clinic at:

City:   Facility:    Dates:  
Division/Classification:

As a condition of obtaining such a sanction the above organization agrees to provide adequate insurance coverage and
employ instructors who provide only the highest quality education.

The approved form will be displayed at the clinic in a conspicuous place.

Print this form and send to ASA of PA, 1081 Pebble Court
Mechanicsburg, PA 17050


 Fee Included; $                 
 

For Office Use Only 


Approved  Denied

ASA State Commissioner: __________________________  Date: ____________