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Please be sure to print before you submit! Click the Print button on the bottom of the form first before you click the Submit button.

Name *
Address *
City *
State *
Zip Code *
Institutional Affiliate
Membership Level *Certified ($50) (you must have ASLTA Certificate)
Associate ($40)
Supporting ($25)
Institutional ($150) NOT for personal membership
E-mail Address: *
Other Email Address
* RequiredCreate Email Forms

You are welcome to add any donations to your payment when you send in the form with your payment. Any extras on the payment will be considered as a donation.
 
Please mail the payment with the form to:
 
2006 ASLTA Membership
PO Box 92445
Rochester, NY 14692-9998
 
Thank you!
 
Mark D. Jones
ASLTA Membership Coordinator