How to become a member

Membership Application

   Name _________________________________   SS # _____________________
   Home Address ______________________________    Hm Ph _______________
   City    ________________________________________    Zip _______________
   E-mail address _______________________________
   Date of Birth   /   /    Married    Y    N     Spouse's Name _____________________

   Certificate # ___________ Granted by State of _____________ Date _________
   Business Name ____________________________________________________
   Business Address   __________________________________   Suite __________
   City ____________________________________________     Zip ___________
   Business Phone   __________________  Fax __________________
   Where should notices be mailed? (Circle one)   Home    Business

   State reasons for desiring to join this organization _________________________
  __________________________________________________________________
   List affiliations with other accounting organizations ________________________
  __________________________________________________________________
   Recommended by   __________________________________________________
   Would you like to be included in the web site membership directory?   Y    N

   Signature of Applicant ______________________________    Date ___________