| NAME___________________________________________ | TITLE: Au.D./Ph.D.
or M.S./M.A. in ____ |
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| ADDRESS________________________________________ | CITY___________________ |
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| STATE_______________ ZIP CODE_______________ | PHONE________________ |
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| EMAIL___________________________________________ | FAX___________________ |
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| EMPLOYER______________________________________ | PHONE________________ |
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| PROGRAM CHAIR SIGNATURE (IF APPLICABLE)_______________________________ |
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| SIGNATURE______________________________________ | DATE__________________ |
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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 | |
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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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