Date:

Clinic:

Address:

City:

State:

Zip:

Phone Number:

800 Number:

FAX Number:

Contact Person(s):

Clinic Owner(s):

Clinic Physician(s):

E-Mail Address:

How did you hear
about ACOL?

Are you a member of:
___ NAF:

___ NCAP:

___ PlannedParenthood:

If you're not a member of one of the above, list
at least 3 references from people in those groups:

1. _______________________
2. _______________________
3. _______________________
4. _______________________

Check other categories that apply to your clinic:

___ Late Abortions Past 20 Weeks

___ IV Sedation or General Anesthesia

___ Medical Abortions with M&M

___ Morning After Treatment

___ Female Tubal Sterilization

___ Pre-Natal Care

___ Men's Services

___ Adoption Services

25-word Descriptive Statement about your clinic. No fluff.
Use as many keywords as possible.

________________________________________________________

OFFICE USE: Do not write below this line

________________________________________________________

___ Received

___ Sent to Programming

___ Up for Approval

___ Approved

___ Changes Sent to Programming

___ Changes Made & Final Link

Search Engine Registration

1. _______________________
2. _______________________
3. _______________________
4. _______________________
5. _______________________

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