NEW MEMBER / RENEWAL FORM 2009

Name	__________________________________________________
Organization	__________________________________________________
Address	__________________________________________________
City/State/Zip	__________________________________________________
Country	__________________________________________________
Phone	__________________________________________________
Fax	__________________________________________________
E-mail	__________________________________________________
Website Address
	__________________________________________________
Additional Names for Sustaining Members
	__________________________________________________ __________________________________________________
___YES, tell me how to subscribe to the APLIC DUPS Listserv! This is a:  _____ new membership ______ renewal _______ new address

1. Make checks payable to APLIC-I (credit cards cannot be accepted). 
   APLIC Tax ID No: 23-7249032.
2. Checks must be in U.S. dollars and payable to a U.S. bank
3. Check the appropriate membership category:

______ individual (developed countries) $50.00
______ individual (developing countries) $15.00
______ student $15.00
______ retired $15.00
______ sustaining (up to 5 individuals) $125.00

TOTAL ENCLOSED $ _________________________

(The membership year is January-December. Memberships will be active from the date of receipt of payment through December 2009.)

4. Mail to:

APLIC-I Treasurer
c/o Julia Cleaver
Ipas Resource Center
PO Box 5027
Chapel Hill, NC 27514 USA

(If you have questions about APLIC-I membership, please contact Kiet Bang (Membership Chair) at bang@pop.psu.edu.)

5. Requests for receipts must include a self-addressed envelope.

6. Contact information provided on this form will appear in APLIC-I’s online membership directory. Please contact Kiet Bang with any concerns at bang@pop.psu.edu.

Home | About APLIC-I | Members | Publications | Conferences | Listservs

Last updated August 12, 2008