American Society For Aesthetics

Donations - Secure Online Donation Form

Campaign/Fund Information
Campaign/Fund *	Rocky Mountain Division or Select a Different Fund

Donation Information
Donation Amount *	$
Payment Method *	Credit Card
Donor Comments

Donor Information

First Name *
Middle Name
Last Name *
Suffix
Organization
Email *
Address *
Address Cont.
City/Town *
Country *
State	(Reset)
Postal Code*
Phone *

Billing Information
[ Click here if billing address is the same as donor address ]
Name on Card *
Card Type *
Card Number *
Card CVV Num *	What is this?
Exp. Date *	/
Organization
Address *
Address Cont.
City/Town *
Country *
State	(Reset)
Postal Code*
Billing Phone *

ASA MEETINGS: I have read and understand the ASA Policies on Discrimination, Harassment, and Respectful Behavior. I agree to comply with those policies at ASA meetings I attend. I understand that violations of these policies may result in removal from the meeting and/or a prohibition against attending future meetings. https://aesthetics-online.site-ym.com/resource/resmgr/files/ASA_policies_on_discriminati.pdf

MEMBERSHIPS: I understand that memberships are non-refundable and non-transferable. I also understand that the ASA membership year is January 1 - December 31 and that ASA is unable to pro-rate memberships.

I Accept the Terms of Use

The Cardholder stated above has authorized this payment. If this payment is part of a recurring series of payments, the Cardholder understands the terms and amounts of those recurring payments, and authorizes payment for each of them. Cardholder consent will expire once all scheduled recurring payments have been processed, or if all future recurrences are cancelled. The Cardholder acknowledges that specific payment dates may vary. Examples include, but are not limited to: payment dates falling during weekends, holidays, or during system outages. In order to facilitate the processing of those recurring payments, stored credentials will be used. Those stored credentials will only be used to process payments that are part of this series of recurrences. In order to use those stored credentials for any other payment, Cardholder re-authorization will be required. In the event that a consent agreement must be modified, the new agreement will be sent to the email address associated with the invoice.

The Cardholder understands the terms and authorizes the payment(s).