Request for AST endorsement of an educational activity Payment form for endorsement request fee of activity: Activity contact: Date of endorsement request: DATE, YR Amount of nonrefundable endorsement request fee: $250.00 USD Please complete credit card information and return this form by fax (856-581-9604) or by mail. Do not scan/email this document as that is not a secure method of transferring credit card information. Name on card: Card #: Expiration Date: Signature: Billing Address 1: Billing Address 2: Billing City and State: Billing Zip/Postal Code: Email Address: If you are unable to pay with a credit card, a check is acceptable. Include a copy of this payment form with check and mail to: American Society of Transplantation ATTN: Education Endorsements 1120 Route 73, Suite 200 Mount Laurel, NJ 08054 Please contact info@myAST.org or 856-439-9986 with questions. AST TAX ID # 42-1182936 OFFICE USE ONLY – Miscellaneous Deposit Form to accounting AST Endorsement: 3107-135-00-000
Request for AST endorsement of an educational activity Payment form for endorsement request fee of activity: Activity contact: Date of endorsement request: DATE, YR Amount of nonrefundable endorsement request fee: $250.00 USD Please complete credit card information and return this form by fax (856-581-9604) or by mail. Do not scan/email this document as that is not a secure method of transferring credit card information. Name on card: Card #: Expiration Date: Signature: Billing Address 1: Billing Address 2: Billing City and State: Billing Zip/Postal Code: Email Address: If you are unable to pay with a credit card, a check is acceptable. Include a copy of this payment form with check and mail to: American Society of Transplantation ATTN: Education Endorsements 1120 Route 73, Suite 200 Mount Laurel, NJ 08054 Please contact info@myAST.org or 856-439-9986 with questions. AST TAX ID # 42-1182936 OFFICE USE ONLY – Miscellaneous Deposit Form to accounting AST Endorsement: 3107-135-00-000
Endorsement%20fee%20payment%20form%202018.docx