UPAC Membership Application

(PLEASE PRINT)

NAME____________________________________________________________

ORGANIZATION (if applicable): _______________________________________

ADDRESS: _______________________________________________________

________________________________________________________________

CITY:  ____________________________________________________________

STATE:  _____________________________   ZIP:  _______________________

PHONE NO.(__________)____________________________________________

FAX.(__________)__________________________________________________

Email_____________________________________________________________

DESIRED STATUS:

Professional ______ $25.00
voting membership; subscription to newsletter and journal

Student ______ $12.50
voting membership; subscription to newsletter and journal

Associate ______ $12.50
voting membership; subscription to newsletter. appropriate for professionals not wishing to receive the journal

Affiliate ______ $12.50
voting membership, subscription to newsletter. appropriate for USAS/URARA/USHS members not wishing to receive the journal

Subscriber ______ $12.50
subscription to journal only, no membership

IS THIS A RENEWAL?

YES ________, Specify year to apply dues ______________
NO _________

Would you be willing to serve in a volunteer capacity, as a UPAC officer, member of a committee, advisor or assistant to a USAS Chapter?
YES (please specify) ________________________________           NO  ________