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Printable pdf

2013 MEMBERSHIP APPLICATION

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NAME___________________________________________TITLE: Au.D./Ph.D. or M.S./M.A. in ____
  
  
ADDRESS________________________________________CITY___________________
  
  
STATE_______________        ZIP CODE_______________PHONE________________
  
  
EMAIL___________________________________________FAX___________________
  
  
EMPLOYER______________________________________PHONE________________
  
  
PROGRAM CHAIR SIGNATURE (IF APPLICABLE)_______________________________
  
  
SIGNATURE______________________________________DATE__________________
  

Annual dues are $25.00, Good Thru January 31, 2014. Checks Made Payable to KAA.
A late fee of $10.00 will be assessed for if not postmarked by January 31, 2013

You  MUST pay dues by April 1, 2013 to be eligible for member fees for the 2013 KAA Conference.

Are you Board Certified in Audiology, by the ABA?

Yes  or  No
(This Does Not Mean CCC-A) 

IF YOU ARE INTERESTED IN CONTRIBUTING TO OUR KAA-PAC
PLEASE FILL OUT INFORMATION BELOW.
(NO CORPORATE CHECKS CAN BE ACCEPTED FOR A PAC CONTRIBUTION)

PERSONAL CHECKS ONLY – SEPARATE FROM DUES.

SUGGESTED PAC AMOUNTS (CHECK ONE)

___$25.00

___$50.00

___$75.00

___$100.00

Other $____________

TOTAL ENCLOSED

 
MEMBERSHIP - $25.00 / $35.00 (Late)KAA-PAC  -$___________
CHECK #____________ CHECK #____________
(Make check payable to KAA)(Make check payable to KAA-PAC)


PLEASE SEND YOUR PAYMENT TO:
KAA
1707 Cumberland Falls Hwy
Suite U-7
Corbin, KY 40701

 
 
 

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