Membership Mailing List Order Form The Society of American Gastrointestinal and Endoscopic Surgeons rents our membership list to both members and non-members of the Society. A completed order form and a sample of the mailer or mailers you intend to distribute can be placed by mail, fax or email. Once the order is received and processed, the mailing list will be sent to you. Please allow 2 weeks for normal processing. Please note that the prices listed are for a ONE TIME USE ONLY. Additional uses may be purchased at a 50% discount if the list is used again within 60 days of the original purchase date. Payment by check payable to SAGES or credit card (VISA, MasterCard, AMEX or Discover) may be included with your order or you can request that you be mailed an invoice. PLEASE NOTE, WE DO NOT DISTRIBUTE EMAIL ADDRESSES. Once a mailing list has been delivered, there are no refunds. Company*Name* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Please Upload a Copy of the Mail Distribution* Drop files here or Accepted file types: jpg, gif, png, pdf, doc, docx. Delivery Method*Emailed Excel SpreadsheetUS Mail (Avery Labels)FedEx (Avery Labels)FedEx (Use Your Account Number)FedEx Account Number*Which category describes you?*SAGES MemberNon-Member Surgeon/InstitutionIndustry/CorporateBilling Type*SAGES MemberNon-Member Surgeon/InstitutionIndustry/CorporateSAGES Member Name*List Contents* Active Members (Full Surgeons) Candidate Members (Residents and Fellows) Allied Health Professionals (Non-Surgeons) International Members All Members (US and International) All Members (US Only) Total $0.00 Payment Method*Credit CardCheck (Please send Invoice)Purchase Order Number*Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name