Membership Application

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Membership Category
Active Membership / US$ 75.00:
Student Participation / US$ 10.00:
Listing Category
Consultant Section:
Company Section:
Personal Information
First Name:
Last Name:
Spouse First Name:
Home Address:
City:
State:
Postal Code:
Country:
Phone:
(Country Code):
(City Code):
Birth Date:
Citizenship:
Company Name:
Street Address:
Suite Number:
Postal Code:
Mailing Address:
Postal Code:
City:
State/Province:		Choose State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia 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 Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming All States All Provinces British Columbia Alberta Saskatchewan Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Yukon
Country		Choose Country United States Canada Afghanistan Albania Algeria All Countries American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Belorussia Benin Bermuda Bhutan Bolivia Bosnia Herzegovina Botswana Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Islands Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Eslovaquia Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Islands Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hrvatska Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Island Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Letonia Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mexico Micronesia Moldavia Monaco Mongolia Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kits and Nevis Saint Lucia Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka St. Pierre and Miquelon Sudan Surinam Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Wallis and Futuna Islands Western Sahara Yemen Zaire Zambia Zimbabwe
Phone
(Country Code):
(City Code):
number:
Fax
(Country Code):
(City Code):
number:
Title:
Telex:
Answer Back Code:
Email:
Education
College/University/Institurion (1):
Major or Course of Study:
Years Attended:
Degree Received:
College/University/Institurion (2):
Major or Course of Study:
Years Attended:
Degree Received:
College/University/Institurion (3):
Major or Course of Study:
Years Attended:
Degree Received:
Professional Experience		Describe your professional experience, thereby establishing your qualifications for membership. Please review the qualifications for membership and supply the information that will establish the category of membership for which you qualify. Lack of pertinent information may prevent prompt processing of your application. Use additional pages as necessary.
Present Employer:
Address:
Title:
Date
From:
To:
Supervisor:
Title:
Duties and Responsibilities:
Previous Employer:
Address:
Title:
Date:
From:
To:
Supervisor:
Title:
Duties and Responsibilities:
Recommendations		Please provide the names of three (3) AIPN active members who will provide letters of recommendation on your behalf. These Letters should be forwarded under separate cover to the attention of: Membership Committee AIPN P.O. Box 5186 Katy, TX 77491-5186 USA
1:
2:
3:
User ID: (Use Email Address)
Password:
Verify Password:

 

 

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