| NAME___________________________________________ | TITLE: Au.D./Ph.D./M.S./M.A./Student |
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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/SCHOOL______________________________ | 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 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, 2010 |
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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. |
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| SUGGESTED PAC AMOUNTS (CHECK ONE) |
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___$25.00 | ___$50.00 | ___$75.00 | ___$100.00 | Other $____________ |
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TOTAL ENCLOSED | |
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| FELLOW MEMBERSHIP - $25.00 / $35.00 (Late) | KAA-PAC -$___________ |
| STUDENT MEMBERSHIP - FREE / $10.00 (Late) | |
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| 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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