CACS Allied Membership Application

CACS Allied Health Application

Full Name*
First Middle Last
Professional Title*
Company Name*
Office Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Fax
Email*
Website
Are you licensed or certified?*
License or Certification #*
Date Obtained*
Organization Obtained From*
State/Country Obtained From*
MM slash DD slash YYYY
Is Your License or Certification in Effect & Unrestricted?*
List Memberships and Associations
How long have you been in the cosmetic industry?*
Terms and Conditions
Consent
I agree to the membership terms and conditions.
Membership Agreement
I agree that membership in CACS is a privilege, not a right. I recognize that the contents of this application will be seen by individuals working in and for CACS. I agree CACS membership will be revoked or terminated for such cause as may be deemed appropriate through the Bylaws for the Academy. Moreover, I acknowledge that membership in CACS does not qualify myself as certified to practice cosmetic surgery and that membership in said Academy is for educational purposes to advance knowledge, experience and skills. I hereby acknowledge and authorize use of the information provided for dissemination of information from or approved by CACS.

Additional Terms
- Dues rates and fees for the Academy are determined by the members of the Board of Trustees and can change without any prior notification, written or otherwise. CACS holds all rights and privileges to determine and set dues and application fees as appropriate.
- CACS will automatically renew your membership annually in December until you cancel in writing info@calcosmeticsurgery.org.
Membership – Allied Health*
- ($250.00)
Total
$0.00
Credit Card
Card Details
Cardholder Name

CACS Allied Health Application

Terms and Conditions