Name: *

Title: *

Organization: *

E-mail Address: *

Send mail to my: Work Home

Business Address: *

City: *

State: *

Zip Code: *

Work Phone: *

Work Fax:

Personal Address:

City:

State:

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Home Fax:

Annual dues are $125 for one calendar year.

Student dues are $35 for one calendar year.

Dues received after October 1st are credited for the following year.

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Payment Method: * Check Credit Card