IAEP Membership Application

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(Print this page and use as "mail in" form.)

____ Check here if this is a renewal.

Name_______________________________________

Position/Title___________________________________

Department/Program______________________________________

Company/Institution Name_________________________________________

Address______________________________________

City_____________________State_____Zip_________

Work Phone_________________ Work Fax__________________

E-MAIL:_____________________________

SPECIALTIES:____________________________________________________

Home Address*

City_____________________State_____Zip_________

Home Phone_______________

*Home address will be published in directory unless another address is given.

MAIL TO: (please circle your choice)------Business..........Home

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Membership category:

____General...............$35/year (attach resume)

____Associate............$35/year (attach resume)

Education____________________________________________

Years experience________________________________

Specialties__________________________________________________

____Student...............$17/year (attach transcript)

Education____________________________________________

Years completed________________________________

Estimated date of completion________________________________

____Institutional...........$125/year (Please put name and title of representative above.)

____Corporate...........$175/year (Please put name and title of representative above.)

IAEP Member who Referred me: _________________________________________

Make your check payable to "IAEP".
Send application, resume, vita, or transcript to:
Illinois Association of Environmental Professionals
P.O. Box 81551
Chicago, IL 60681-0551