ASAPAC Contribution Form

Federal law requires ASAPAC to use our best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose donations exceed $200 in a calendar year.

* Required Fields   


* Check if you are an ASA member and have used your personal login information
Check if you are an ASA staffer and have used your personal login information
Check if the contribution is from spouse or immediate family member
* First Name Please do not enter middle initial.
* Last Name
ASA Member No.
Contact Information
* Street Address
To use another address for this PAC Contribution please do the following:
Note: Changing your address WILL change your address for all ASA communications
1) Click Here to update your ASA Primary Address
2) After updating your address click on ASAPAC
3) Click on Contribute
* City
* State and Zip
* Component Society
* Occupation
  (please no abbreviations)
* Employer
  (please no abbreviations)
* E-Mail

One Time Contribution  

Circle of Distinction donor level is $500 - $999.
Chairman's Council donor level is $1000 and above.
Maximum contribution is $5000 per calendar year.
Guideline Amounts are Merely Suggestions.

$20 (Resident)
Other   $ 
     (Clear All Donation Options.)

Recurring Contribution  

Recurring contributions will be valid for a minimum of 12 months and a maximum of 24 months. Your first contribution will occur today and the remaining contributions will be made the same date every month.

The selected amount will be charged each month to your credit card.
For this type of contribution, the credit card expiration date should be greater than or equal to the date you select for termination of contribution.
You have the option of canceling this process at any time by contacting Michelle Mathy at

$41.67 (Circle of Distinction Club Level)
$83.34 (Chairman's Council Club Level)
Other   $ 
  I would like this contribution to automatically recur:
Until I contact you Until: Month Year Number of Months
  *recurring contributions can be no more than 24 months.

(Corporate and Business Credit Cards Prohibited.)
Type of Personal Credit Card



American Express
* Credit Card Number  *Do not include dashes or spaces
* Expiration Date
* Name on Card
  Please check if you wish to receive an ASAPAC pin.
  Note: The ASAPAC Fiscal Year runs from October 1st to September 30th.
  Contributions to ASAPAC are not deductible as charitable contributions for federal income tax purposes. Participation in ASAPAC is voluntary. You may refuse to contribute without reprisal.
  Questions or comments regardng ASAPAC may be directed to Michelle Mathy in the ASA Office of Governmental and Legal Affairs at 202-289-2222 ext 140 or
  Please check the boxes below to confirm that the following statements are true:
  I am making this donation from my own funds, not those of another, and through my personal credit or debit card for which I have a legal obligation to pay, and not through a corporate or business entity card or the card of another.
  I am at least 18 years of age, and I am a U.S. citizen or legal permanent resident of the U.S. residing in the U.S. and a current dues paying ASA member. Retired members are also permitted to contribute to ASAPAC.
  Note: Due to new security policies for some credit card issuers, please contact your card issuer if your transaction fails.
  We are not able to process a contribution for you. Please contact ASA at (847) 825-5586.

ASA Political Action Committee
1061 American Lane
Schaumburg, IL 60173-4973
(847) 825-5586

About ASA: The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient. Since its founding in 1905, the Society's achievements have made it an important voice in American Medicine and the foremost advocate for all patients who require anesthesia or relief from pain.