1. Name (Mr./Ms.)_____________________________________________________

Home Address o ______________________________________________________

Office Address o _____________________________________________________
******please check the box above for which address you prefer as your primary mailing address******

4. Office & Home Telephone Numbers _______________________________________________________________________

Fax Number__________________________________________________________

E-Mail Address ______________________________________________________

Firm, Corporation, Teaching or Government Institution
_______________________________________________________________________

8. Name of School/Graduation Date (If you are a Student)

_______________________________________________________________________

9. Other Professional and Academic Membership

_______________________________________________________________________

10. Are you a member of any political organization and/or foreign association or organization
_____________________________________________________________________

Name(s) _____________________________________________________________
Country of origin______________________________________________________
Citizen of_____________________________________________________________
Election to membership requires approval by the Board of Directors and a published notice of the application to the general membership. The process takes two to three months. Membership fee: $30

I hereby state that everything on this form is true and correct and I agree to abide by the Code of Professional Responsibility, the Articles of Incorporation and the By-Laws of the Association.

Applicant Signature/Date

_________________________