Membership Registration – Affiliate

  • Membership Type - Affiliate

    Affiliate

    You will be able to complete the payment after you have confirmed your e-mail address.

  • Member Info

    If Yes is selected, your info will appear in the Member Locator/Search. Please note, the following information will be available publically: First name, Last name, Email, City, State, Postal Code, Race/Ethnicity, Languages, Licensed in States, Specialty. Students, Affiliates, and Associates will only appear on the Private Members only directory.

  • Contact Info

  • This email address will be used as your login username, to access the listserv, and displayed in the member directory (optional). Please note that we will not be able to honor requests to change the email address to be used for access to the listserv.
  • Use this field if you would like an alternate email for the Google Group Listserv than the email you are using to sign up.
  • Minimum length of 8 characters.
  • Required phone number format: (###) ###-####
  • Required phone number format: (###) ###-####

  • Please set or type your location on the map that you would like to display in the members directory (i.e. Tokyo, Japan or 123 Smith Street, San Francisco CA, USA)

  • Please set your location on the map that you would like to display in the members directory.

  • Personal Information

  • (.pdf or .docx only)