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)
  • 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)