Part 1: Member Information

Prefix: (Example: Dr, Mr, Ms, Mrs, Miss, or military rank)

*First Name:

Middle Initial:

*Last Name:

Title or Position:

*Affiliation:

Part 2: Contact Information

Address Type: Home Work

Organization/Institution:

Department:

*Street Address:

*City:

State: States and territories... Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip/Postal Code:

Office Telephone: (Example: 555-123-4567 x890)

Home Telephone:

Fax Number:

*Email Address:

Part 3: Demographic Information

*Major Field:

Specialty:

*Highest Degree Completed:

Degree Institution:

Expected Degree:

Year Expected:

*Gender: Male Female

Employment Sector: Select One

University
Four Year College
Two Year College
Government
Non-Profit
School Administration
School Teacher
Research/Business
Retired
Other: Please clarify