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KAA Bylaws

2008 MEMBERSHIP APPLICATION
Membership Good through January 31, 2009

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NAME___________________________________________ TITLE: Au.D./Ph.D./M.S./M.A./Student
   
   
ADDRESS________________________________________ CITY___________________
   
   
STATE_______________        ZIP CODE_______________ PHONE________________
   
   
EMAIL___________________________________________ FAX___________________
   
   
EMPLOYER/SCHOOL______________________________ PHONE________________
   
   
PROGRAM CHAIR SIGNATURE (IF APPLICABLE)_______________________________
   
   
SIGNATURE______________________________________ DATE__________________
   
   

Annual dues are $25.00 for Fellows. Dues are waived for Student Members.
A late fee of $10.00 will be assessed for Fellows & Students if not postmarked by January 31, 2008

   

Are you currently enrolled in an Au.D. Program?

Yes  or  No

Residential  or  Online

 

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 / $35.00 (Late) KAA-PAC  -$___________
STUDENT MEMBERSHIP - FREE / $10.00 (Late)  
   
CHECK #____________ CHECK #____________
(Make check payable to KAA) (Make check payable to KAA-PAC)


PLEASE SEND YOUR PAYMENT TO:
KAA
1717 HIGH ST. STE. 2-C
HOPKINSVILLE, KY 42240

 
 
 

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