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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, 2008 |
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Are you currently enrolled in an Au.D.
Program? |
Yes or No |
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Residential or
Online |
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Are you Board Certified in Audiology, by the
ABA? |
Yes or No |
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(This Does Not Mean CCC-A) |
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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) |
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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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MEMBERSHIP - $25.00 / $35.00 (Late) |
KAA-PAC
-$___________ |
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STUDENT MEMBERSHIP - FREE
/ $10.00 (Late) |
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CHECK #____________
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CHECK #____________ |
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(Make check payable to KAA) |
(Make check payable to
KAA-PAC) |
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PLEASE SEND YOUR PAYMENT TO:
KAA
1717 HIGH ST. STE. 2-C
HOPKINSVILLE, KY 42240
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