The membership year is from January 1, 1999 through December 31, 1999.
Professional member ($30/year)
Student Member ($20/year)
Name
__________________________________________________________________________Employment
__________________________________________________________________________Address
__________________________________________________________________________City/State/Zip/Phone
__________________________________________________________________________Home Address
__________________________________________________________________________City/State/Zip/Phone
__________________________________________________________________________email Address/FAX number
__________________________________________________________________________Academic Degree/School
__________________________________________________________________________Years in Field
___________
Please check place a check where you would be interested in any of the following committee's. You may check more than one.
______ Annual Meeting
______ Budget
______ Career Service Bulletin
______ Ethics
______ Licensure
______ Membership
______ NewsletterPlease make check or money order payable to Julie Guidry (Treasurer).
Mail to:
Julie Guidry
Cameron Hospital
416 East Maumee Street
Angola, IN 46703