Membership Application

First Name:
Last Name:
E-Mail:
Street Address:
City:
State:
Zip:
Country:
Your academic department:
Your age:
Your birth month (e.g. October):
Where did you hear about us?
Would you like to receive occasional news by email?
Are you interested in serving on the Board of Directors?
Are you interested in serving on any of the following committees?	Research Web Site Development Membership Converence Development Fund Raising Marketing E-Magazine Health Benefits Wages Select Committee
Are you currently an instructer on ground?
How long?
Are you currently an instructor online?
How long?
How many courses do you teach (total)?
Which courses do you teach?
Where do you teach (optional)?
Are you open to receiving surveys from this organization in order to help us better serve you?

Thank you for your interest in membership.