Arkansas Speech-Language-Hearing Association

Arkansas Speech-Language-Hearing Assoc. Membership App.
  1. First Name(*)
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  2. Middle Name
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  3. Last Name(*)
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  4. Recruited or Referred by
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  5. Membership Categories




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  6. Renewing Member Late Fee
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  7. Credit Card Convenience fee
    $3 Credit Card Convenience Fee
  8. Total
    $0.00

  9. Former Student Members will receive a 10.00 discount on initial Full member dues provided they have current student membership status when they apply.
  10. SLP/AUD # (students put 0)(*)
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  11. Home Address
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  12. City
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  13. State
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  14. Zip
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  15. Home Phone
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  16. Email Address(*)
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  17. Place of Employment
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  18. Address
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  19. City
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  20. State
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  21. Zip
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  22. County
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  23. Work Phone
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  24. Fax
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  25. Full & Associate Members:
  26. Academic Degree
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  27. Year
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  28. Institution
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  29. Certification/Licensure (check all that apply)
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  30. Student Members:
  31. I am currently a full-time undergraduate/graduate (circle one) student at:
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  32. Estimated Date of Graduation:
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  33. Name of Program Chair or Advisor:
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  34. * Membership dues are not deductible as charitable contributions for federal income tax purposes. In addition 21 % of your dues spent for governmental relations are not deductible as a business expense.