Individual Membership Application

Individual Membership Application
For check or money order use only

For credit card payments visit this page

Full Name *

First/Given Name MI Last/Family Name

Position/Title *

College/University *

For Organizations/Colleges/Universities not listed, please select "other" and specify in Organization/Other box below.

Organization/Other

Contact Information

Street Address *

Street Address Line 2

City *

State/Province *

Postal/Zip Code *

Country *

Phone *

Preferred Email Address *

Work Personal

Work Email *

Personal Email *

example@example.com

Fax

Date of Birth

Month Day Year

Veteran Status

U.S. Veteran/Active Duty Member Parent of U.S. Veteran/Active Duty Member Dependent of U.S. Veteran/Active Duty Member U.S. Veteran Descendant Partner or spouse of U.S. Veteran/Active Duty Member

Membership Rates and Types

Membership Rates

Currency in U.S. Dollars

Chapter Only Membership Type

Preferred Chapter

Membership in an ACPA Chapter is now included in our membership rates!

Interested in joining additional chapter(s), please list the chapter(s) below.

Professional Experience

Highest Degree Earned *

Position Level *

Years in the Field *

Primary Job Function *

Secondary Job Function *

Entities

*Use Ctrl or Command to make multiple selections

Networks, Coalitions, and Communities of Practice

Commissions

Would you like to add Hardcopies of JCSD and About Campus to your membership for an additional fee of $21? *

No, I'm fine with digital copies! Yes, please - add $21 to your total below.

Total Dues Amount

U.S. Currency. Please add the ACPA membership fee or chapter only fee you selected above, plus the fees for hardcopies of publications if applicable.

Signature *

Print Name *

Date *

Month Day Year

Check/Money Order Number

Please check if you do not want to be included in the following:

Online membership directory

*Please Print This form and fax it to 202-827-0601* Acknowledgement and Terms of Use: I acknowledge that the information in the above form is correct to the best of my knowledge. Please allow 3-5 business days for processing. For check or money order use only

Checks can be sent to American College Personnel Association, c/o PNC Bank, P.O. Box 645851, Pittsburgh, PA 15264-5256

For credit card payments visit this page

One Dupont Circle NW, Suite 300, Washington, DC 20036-1188, USA Tel: 1.202.835.2272 Fax: 1.202.296.3286