Institutional Membership and Sponsorship Application "*" indicates required fields Institution Name*Institution Contact Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands PhoneEmail* Website* Institution LogoAccepted file types: jpg, png, Max. file size: 64 MB. If you cannot provide your logo now, you may email it separately to julia@surgicaleducation.com.Institutional Level MembershipCOMPLIMENTARY REGISTRATIONS FOR INSTITUTIONAL MEMBERS Once your membership level is confirmed, you will receive the complimentary registration discount code to distribute to the designated registrant(s) at your institution. Designated registrants will enter the discount code when registering online for the Annual ASE Meeting. If any designated registrant has previously registered for the meeting, the fee will be reimbursed. REMINDER:The complimentary registration is for the ASE Annual Meeting only (full meeting, not to include pre-meeting courses or events that have an additional fee). DEADLINE TO USE COMPLIMENTARY REGISTRATION CODE: APRIL 10, 2026. Upon receipt of your membership application, you will also receive information on reserving your tickets for the ASE Banquet.Select your membership levelselect onePlatinum Level Membership - $7,500.00Gold Level Membership - $5,000.00Silver Level Membership - $2,500.00Platinum Level Price: Includes: Five (5) complimentary ASE Annual Meeting registrations for residents, fellows, medical students or education administrators (full meeting, not to include pre-meeting courses or events that have an additional fee) One (1) complimentary registration for Vice Chair (full meeting, not to include pre-meeting courses or events that have an additional fee) Five (5) complimentary tickets to the ASE Awards Banquet* Recognition on break slide and signage with logo Recognition of support by ASE President during opening and closing remarks and Awards Banquet Opportunity to display brochures/literature in the registration area Banner ad in ASE meeting app with hyperlink to company website Membership listing in the ASE meeting app Acknowledgement as Platinum level member on ASE website throughout the year *Additional tickets can be purchased.Gold Level Price: Includes: Four (4) complimentary ASE Annual Meeting registrations for residents, fellow or medical students (full meeting, not to include pre-meeting courses or events that have an additional fee) Three (3) complimentary tickets to the ASE Awards Banquet* Recognition on break slide and signage with logo Recognition of support by ASE President during opening and closing remarks and Awards Banquet Opportunity to display brochures/literature in the registration area Banner ad in ASE meeting app with hyperlink to company website Membership listing in the ASE meeting app Acknowledgement as Gold level member on ASE website throughout the year *Additional tickets can be purchased.Silver Level Price: Includes: Three (3) complimentary ASE Annual Meeting registrations for residents, fellow or medical students (full meeting, not to include pre-meeting courses or events that have an additional fee) Two (2) complimentary tickets to the ASE Awards Banquet* Recognition on break slide and signage with logo Recognition of support by ASE President during opening and closing remarks and Awards Banquet Opportunity to display brochures/literature in the registration area Membership listing in the ASE meeting app Acknowledgement as Silver level member on ASE website throughout the year *Additional tickets can be purchased.Sponsorship OpportunitiesSelect your opportunityselect oneLittle Scrubs Club - $5,000URiM Trainee Scholarship - $2,000Finding Aspiring Surgeons for Tomorrow Community Outreach Event - $1,500Family Care Grants - $1,500Scientific Posters - $1,500Refreshment Breaks - $1,500ASE Meeting App Banner Ad - $1,500Little Scrubs Club Price: The ASE will be offering a fully licensed childcare service on-site during the 2026 Annual Meeting. Located on the same floor as the general session room, meeting attendees can rely on: safe, secure, and supervised care for children ages six months to 12 years. age-appropriate activities including arts, games, and storytelling qualified, background-checked childcare professionals flexible scheduling options to suit attendee schedules By sponsoring this brand new initiative, you'll be allowing attendees peace of mind, knowing that their children are nearby in a safe, engaging and nurturing environment.URiM Trainee Scholarship Price: The ASE DEI committee is offering two travel scholarships in the amount of $1,000 each for trainees who are considered underrepresented in the surgical community and who are interested in attending the Annual Meeting. The scholarship funds would be used to cover the costs of meeting attendance such as airfare and hotel lodging. This initiative is in keeping with the ongoing mission of the ASE to make a home for all in the surgical education community, encompassing a commitment to Diversity, Equity and Inclusion (DEI). Sponsorship will include: Recognition on break slide with logo Recognition of support by ASE president during opening and closing remarks and Awards Banquet Acknowledgement in ASE meeting app with logo and web linkFinding Aspiring Surgeons for Tomorrow Community Outreach Event Price: This event will be organized jointly with the APDS to spread awareness of career opportunities in the medical field. Monetary and in-kind sponsorships (laparoscopic box trainers) will be accepted. Sponsorship will include: Recognition on break slide and signage with logo Recognition of support by Event Chair during event Recognition of support by ASE and APDS presidents during opening and closing remarks and Awards Banquet Acknowledgement in meeting apps with logo and web linkFamily Care Grants Price: Several $500 scholarships will be awarded to alleviate childcare burdens for ASE members traveling to the meeting. These scholarships can be used to support travel of another caretaker to the meeting, childcare in Atlanta, or to secure childcare arrangements at home while the ASE member attends the meeting in Atlanta. This initiative was launched to encourage in-person meeting attendance by ASE members in the early stages of their career. Sponsorship will include: Recognition on break slide with logo Recognition of support by ASE president during opening and closing remarks and Awards Banquet Acknowledgement in ASE meeting app with logo and web linkScientific Poster Price: The posters provide an opportunity for depicting ideas and research results. In addition, they provide a chance to discover and share activities in surgical education and to have individual discussions with the poster presenters. Requested abstract topics for the meeting include: AI Assessment Curriculum Development Diversity, Equity, and Inclusion Education Technology Faculty Development Global Surgical Education Interprofessional Education Leadership Program Evaluation Recruitment and Selection Simulation Teaching Methods Wellness/Well-Being Other Sponsorship will include: Recognition on break slide and signage with logo Recognition of support by ASE president during opening and closing remarks and Awards Banquet Acknowledgement in ASE meeting app with logo and web linkRefreshment Breaks Price: The refreshment breaks will be held in the exhibit area, in the foyer immediately outside of the general session room. Sponsorship will include: Recognition on break slide and signage with logo Recognition of support by ASE and APDS presidents during opening and closing remarks and Awards Banquet Acknowledgement in meeting apps with logo and web link ASE Meeting App Banner Price: Scrolling advertisement on the home page of the ASE meeting app (includes hyperlink to advertiser’s website) PaymentPlease make check payable to the Association for Surgical Education and send to: Association for Surgical Education 11300 W. Olympic Blvd., Suite 600 Los Angeles, CA 90064 Memo: Institutional Sponsorship For more information, please contact Jenay Root at tel: 310-215-1226, ext. 127 or email: jenay@surgicaleducation.com Payment Method*select oneCreditCheck (Please send invoice)Total Credit Card* American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name
