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Application For Membership
•
If you apply for
membership, please complete the application. If you are a member, please update
your application.
•
Dues are for the
Calendar Year.
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Regular
Members,...............($20)
Student/Post-doctoral,.................($10)
Checks and money orders should be made payable
to Dr. Ali Banijamali, Director of Membership.
Membership Type:
□
Regular
□
Other
Name:
(First) (Middle) (Last)
Highest earned degree(s):
Occupation:
Affiliation: Title:
Addresses:
Work:
(Street Address/ P.O. #):
(City):
(State): (Zip Code): (Country):
Home:
(Street Address/ P.O. #):
(City):
(State): (Zip Code): (Country):
Telephone Number(s):
(Work): (Home): (Fax):
E-Mail:
Teaching/ Research Area(s):
Would you like to participate in ICA activities
as a board member? □Yes
□No
I approve of the Association objectives and
hereby apply for membership in ICA-ACS.
Signature: Date:
Please mail your application and Dues to
Director of Membership:
Dr. Ali R. Banijamali, 35 Meadowbrook Lane,
Woodbury, CT 06798.
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